Please fill out before your first training session. Name (required) Email (required) Address Line 1 Address Line 2 Phone Date of Birth Gender MaleFemale Occupation Health, Fitness and Nutrition Goals Have you ever worked with a Fitness Instructor? YesNo If so, what did you like/dislike about your experience? MEDICAL INFORMATION Hospitalizations Disabilities Congenital Disorders Are you currently under a doctor's care? YesNo Date of last check-up Height Weight Recent Weight Loss or gain Desired Weight List all current medications & reason for taking them Are any of these medications beta blockers? Are you allergic to any medications? Any cardio or cerebrovascular diseases / situations? Do you ever experience chest pain w/ exertion? YesNo Do you ever get light headed or short of breath? YesNo EKG NormalAbnormalNever Taken Date & results of last stress test Date & results of last bone density test Resting Heart Rate Blood Pressure Blood Chemistry Values Cholesterol LDL HDL Kidney Function Liver Function BUN Glucose TG Creatinine Do you smoke cigarettes? YesNo Surgeries / Operations Medical Conditions (Current or Past) Diabetes Asthma Easting Disorders Rheumatic Fever Gallstones Digestive Disorders Cancer Anemia Pregnant Hypoglycemia Shortness of Breath Fainting Hiatal Hernia Kidney Stones Gout Stomach Pain Fatigue Joint Pain or Disorders Osteoporosis Family History NUTRITION INFORMATION Food Allergies or Intolerances Likes / Dislikes List all Vitamins & Nutrition Supplements Past Diet Programs Number of meals and snacks eaten daily? Are most of your meals eaten at home or restaurants? Do you have any gastrointestinal discomfort after eating? Are you on any dietary restrictions? Please describe your workouts Diet Recall. Please list average daily food items below Meal 1 Meal 2 Meal 3 Meal 4 Meal 5 Meal 6 Please read and fill out the following: I, , understand that I will be participating in a personal fitness training program that will include weight training, cardiovascular, stretching and balance oriented exercises. The session may also include boxing, kick boxing, and / or other exercises as well as nutrition advice. I have been informed and understand that physical exercise has been associated with certain risks, including but not limited to musculoskeletal injury, spinal injuries, abnormal blood pressure responses and in rare instances heart attack or death. Protocols are followed to minimize these risks. Any information that is obtained regarding fitness level and progress will be treated as privileged and confidential and will not be released to any person other than my physician or physical therapist without my further consent. I have read and understand the foregoing consent to participation in said program. I am aware that I may discontinue my participation in this program at any time. In addition, I agree to the following: a. Assume all risk of injury and all risk of damage to or loss of property arising out of my participation in this program or visitation to the facility. b. Release, discharge and waive GJS47, LLC (dba: Great Jones Fitness) and its affiliates from any and all responsibility and liability of injury, including death which may be suffered by the undersigned arising out of, or in any way connected with the participation in this program. c. Indemnify and hold harmless any facility owned, operated or affiliated with GJS47, LLC (dba: Great Jones Fitness). d. All appointments require a 24 hour cancellation notice. Any appointments not cancelled within this period will be subject to a full charge for that session. All sessions purchased are non-refundable. Name Date
