Keystone Fitness Questionnaire Form

Fact sheet - Client Information
Full name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Current Age
What colour appeals most to you?
Are you fully vaccinated for COVID-19?

NoYes
If yes, please indicate date received COVID-19 2nd dose

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Current Occupation
Marital Status

SingleMarriedOther
Do you have children?*

YesNo
Number of boys
Number of girls
Current Weight (lbs/kg) *Please indicate which measurement is used if lbs or kg.*
Current Height (cm) - Check National Identification Card as reference*
How did you find out about us?*

Emergency Contact Information
Emergency contact*

First NameLast Name
Phone number*
Format: (000) 000-0000.
Relationship to Emergency Contact*

Family History
Do you or any family member have a history or Diabetes, High Blood Pressure, Cardiac Disease, Kidney Disease, or any such or related ailments? Please indicate details below*
Do you regularly engage in smoking, alcohol consumption, party/recreational drugs?

YesNoOccasionally
If yes, please state below

Client informations - Liability waiver
I am aware of the risks in observing or participating in the activities offered and sponsored by KEYSTONE FITNESS LIMITED 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 KEYSTONE FITNESS LIMITED is responsible for any damage that would be resulting from a fault of KEYSTONE FITNESS LIMITED and its representatives.
Initials*
Client informations - 12 hour cancellation policy
All cancellations must be received at least 12 hours before your training session in order to avoid forfeiting your session and being charged a $50.00 late cancellation fee. Clients who do not cancel with 12 hours notice agree to forfeit thier scheduled session for the cancellation, plus agree to pay $50.00 late cancellation fee.

KEYSTONE FITNESS LIMITED understands that emergencies happen. We provide every client with one free short-notice cancellation. Meaning your first cancellation with less than 12 hours notice, can be rescheduled to a later date and not incur late cancellation fee. Subsequent short notice cancellations will be charged late cancellation fee, plus forfeiting of training session (meaning no rescheduling possible). The free short-notice cancellation only applies if KEYSTONE FITNESS LIMITED, or your trainer is notified prior to the session start time. No shows are not eligible for the free cancellation.
Initials*

Client information - Signature
Signature*
Today's Date

MonthDayYear
Date
Should be Empty:

Rows	Yes	No
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?
In 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?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
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?
Have you ever experienced palpitations or irregular heartbeats?
Have you previously been diagnosed with any major illness?
Are you currently being treated for any diagnosed medical condition?
Do you have Nausea, Vomiting,, Constipation, Diarrhoea, Acid Reflux, or other Gastrointestinal Issues?

Fact sheet - Client Information

Emergency Contact Information

Health Questionnaire (Par-Q)

Dietary Information

Family History

Client informations - Liability waiver

Client informations - 12 hour cancellation policy

Client information - Signature