Gym health questionnaire Form

Welcome sheet - Client informations
Full name *

First Name Last Name
Birth Date

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Phone Number *

Area Code Phone Number
Emergency contact *

First Name Last Name
Phone number *

Area Code Phone Number
Clients informations - Health questionnaire
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Yes or No *

Yes

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel fain in your chest when you do physical activity?

n the past month, have you had chest pain when you were not doing physical activity?

Do you lose balance because of dizziness or do you ever lose consciousness?

Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?

Do you know of any other reason why you should not do physical activity?

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials *

Clear
Client informations - Liability waiver
I am aware of the risks in observing or participating in the activities offered and sponsored by Jupiter Kickboxing and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death. It is understood that Vsquarefitness is responsible for any damage that would be resulting from a fault of Vsquarefitness and its representatives.
Initials *

Clear
Client informations - Billing policy
I authorize Jupiter Kickboxing to bill my credit card every last day of the month for the services provided during that month.
Initials *

Clear
Client informations - Signature
Signature *

Clear
Email
example@example.com
Date *

Month Day Year
Date

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