15:7 Fitness “Client Intake”

Full Name

First NameLast Name

Birth Date

MonthDayYear

Occupation

Phone Number

Area CodePhone Number

City, State

E-mail

MEDICAL HISTORY

Have you had any family history of chronic disease (heart disease, diabetes, etc.)?

If yes, please list

Have you ever been diagnosed or treated for any chronic disease including asthma?

If yes, please list

Are you currently taking any medication?

If yes, please list

Any other conditions that we need to be aware of (i.e. Past or present injuries, etc)?

If yes, please list

PERSONAL DETAILS

If you have answered YES to any of the above questions, you must obtain a medical clearance prior to carrying out a physical exercise program.

HEALTH RELATED BEHAVIOURS

Do you smoke?

If yes, how many a day?

Do you drink alcohol regularly?

If yes, how much per week?

How many times on average do you eat fast food per week?

Current Weight

Height

How many times a week do you eat fast food?

Food Allergies

Food Dislikes

How many hours of sleep do you normally get per night?

PSYCHOLOGICAL

Please rate the following. One star being negative to five stars being positive

My job stresses me out.

I would rate my current health.

GOALS

Do you have specific goals related to body composition (i.e. weight loss, build biceps etc)?

If yes, please list

Do you wish to achieve any of these goals in a specific time frame?

If yes, please explain

LIABILITY WAIVER Please read carefully before submitting form.

I agree, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with 15:7 Fitness & Nutrition Having such knowledge, I hereby release 15:7 Fitness & Nutrition, their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity.

I hereby assume all risks connected therewith and consent to participate in said program. I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in said fitness program. I promise to not perform given exercises under any influence of illegal or alchoholic substance.

I also agree to 15:7 Fitness & Nutrition's no refund policy. That it is my responsibility to commit myself and make the time to put to work all of the resources, tools, and guidance I am given by the 15:7 Fitness team.

I understand that life happens on both ends of this relationship and that 15:7 Fitness reserves the right to refuse service or continue any services rendered without refund if deemed neccessary, and that My Results are My responsibility.

1-1 In Person Sessions:

I acknowledge and accept that any in person 1-1 training sessions are to be paid in advnace to schdeuling and that I the client agree to commit to 2 months and that I, the client must give a 30 days notice before ending of sessions. If I, the client cannont phsyically attend the sessions, and if I the client quit without notice the sessions will still be deducted as I have not given the adequate 30 days notice for 15:7 to fill that spot.

Please tick box in agreement to the above liability waiver

What services are you wanting to start?

Front Photo

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Side Photo

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Back Photo

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Are you taking any supplements? If so please list below