Physical Activity Readiness Questionnaire

Please fill out before your first training session.

Name (required)

Email (required)

Address Line 1

Address Line 2

Phone

Date of Birth

Gender

Occupation

Health, Fitness and Nutrition Goals

Have you ever worked with a Fitness Instructor?

If so, what did you like/dislike about your experience?

MEDICAL INFORMATION

Hospitalizations

Disabilities

Congenital Disorders

Are you currently under a doctor's care?

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?

Do you ever get light headed or short of breath?

EKG

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?

Surgeries / Operations

Medical Conditions (Current or Past)

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