Please read and complete all questions prior to your fitness session. If you have any questions, don't hesitate to ask. Thank you!
First and Last Name
Emergency Contact Name
Emergency Contact Phone Number
What are some of your fitness or wellness goals?
Describe any regular physical activity or tasks that keep you busy during the day:
List any fitness equipment you have at home. Include sizes of dumbells, etc.
This completed form is required prior to training. It let's us know of any limitations or precautions you may have for physical exercise. Please understand that a medical clearance may be necessary before you start your program. This is to ensure your safety, which is my highest priority.
Please explain any injuries or pain still affecting you:
Do you have any of the following health conditions?
History of heart problems, stroke, chest pain or dizziness
Elevated blood pressure
Breathing or lung problems, like Asthma
Diabetes or metabolic syndrome
Please explain any health conditions that you marked above or otherwise:
Please list any current medications:
I understand that the purpose of the exercise program is to develop and maintain cardiorespiratory fitness, body composition, flexibility, muscular strength and endurance. All exercise prescription components will comply with proper exercise program protocols. The programs include, but are not limited to aerobic exercise, flexibility training, and strength training. All programs are designed to place a gradually increasing workload on the body in order to improve overall fitness. I understand that there exists the possibility of adverse changes when engaging in a physical activity program. I understand that every effort will be made to minimize these occurrences by proper screening and by precautions and observations taken during the exercise session. I understand that there is a risk of injury, heart attack, or even death as a result of my participation in an exercise program, but knowing those risks, it is my desire to partake in the recommended activities.
Please read the Informed Consent and answer below:
I understand that there is a risk of injury, heart attack, or even death as a result of my participation in an exercise program, but knowing those risks, it is my desire to partake in the recommended activities.
Thank you for understanding the value of these policies so that I am able to maintain a professional and fair business for myself and all clients.
Payment & Refunds
Payment: Payment is accepted via cash, check (payable to Real Simple Fitness) or by credit card through my website. Please make payment prior to, or at the time of your first session. Refunds: If you would need to terminate your program early, a refund will be given for any unused sessions.
Fitness Classes: Please schedule each class at least a day in advance. Class may be cancelled if there is not at least 2 participants scheduled. Late Arrivals/Cancellations: Please give me as much notice as possible if you need to cancel your session/class or are running late. A heads up is also helpful if you expect a possible conflict. Ongoing cancellations will result in possibly having to surrender your preferred time slot, or having to discontinue services. Sessions will begin and end at the scheduled time.
I love to take photos from time to time to capture the experience of Real Simple Fitness. Photos will be taken respectfully and tactfully. These photos may be used on our social media, our website or otherwise.
Please read the Photo Release and answer below:
I give my permission to have my photo taken and used responsibility for promotional purposes.
I do not wish to have my photo shared.
As your Fitness Professional, I will treat you and each client with respect and dignity; free of judgment and keep your personal information private and confidential. I will keep my Personal Training Certification in good standing, which requires a current certification in CPR/AED training, and a minimum of continuing education courses. I will follow best business standards within my legal scope of practice and refer you to other professionals for needs I cannot meet.
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