INFORMED CONSENT

Health History

Informed Consent
Name *

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Birthdate

Month Day Year
Date
Health History
Moderate or vigorous exercise should not be a hazard for most people providing it is undertaken as part of a regular program starting from low intensity and progressing gradually. However, some people will need medical evaluation and advice before starting a program, some may need to exercise under medical supervision and some people may only be able to undertake restricted physical activity under medical supervision.

If you answer NO to all the questions, it is reasonable for you to assume that you are in a suitable physical condition to start a regular graduated exercise program.

If you answer YES to one or more question you are first advised to consult your doctor prior to participating in any exercise program.
Any injuries, muscle or joint pain, past or present that would affect your ability to exercise? *

Yes No
Any heart disease, shortness of breath, or other chronic or acute conditions that would impact with your ability to exercise? *

Yes No
Anything within your health history that needs to be disclosed that would negatively affect your health in regard to adding exercise? *

Yes No
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes No
How many times and duration did you exercise in the last 2 weeks? Ex. 4 days for 30 minutes each time?
What type of training do you do (if applicable)? i. e. cardio 3 X per week, weight training 2 X per week or yoga 1 X per week
Goals
What is your short-term and long-term training goal?
What else do I need to know about you to help direct you to the most optimal training plan for you?
Signature *

Clear
2) Informed Consent
I, the undersigned do hereby agree & acknowledge:
My consent to perform an exercise program designed by a trained fitness consultant; where it will be supervised by an appropriately qualified person; unless it is an online program then the exercise performed by the participant will not be supervised by the trained fitness consultant *

Agree Disagree
My understanding that exercises will consist of one or more of the following components: mobility, cardiovascular, strength, agility, speed, power, plyometrics, muscular endurance, stamina, balance, coordination and flexibility. *

Agree Disagree
I fully understand that there are potential risks, i.e. episodes of transient light-headedness or possibly loss of consciousness, and I willfully assume these risks. *

Agree Disagree
My obligation is to immediately inform my in-person coach of any abnormal symptoms that I may suffer while exercising. *

Agree Disagree
I acknowledge that any nutritional or supplementation advice given is not a medical prescription and should be consulted with my healthcare professional. *

Agree Disagree
That I have read, understood, and completed the medical screening questionnaire and obtained medical clearance if necessary. *

Agree Disagree
Date *

Month Day Year
Date
Name *

First Name Last Name
Signature *

Clear
Should be Empty:

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Health History

Health History

Goals

2) Informed Consent