Personal Trainer Client Intake and Liability Form

Fitness with Jazzy
Book for 1st assessment session below:
Client Intake Form
Full Name *

First Name Last Name
Gender *

Male Female
Date of Birth *

Month Day Year
Age *
years
Height *
Inches
Weight *
lb
Phone Number *

Area Code Phone Number
Email *

Confirmation Email example@example.com
What is the best way to contact you? *

Phone call Email Text Messenger
Lifestyle Information
What do you do for a living? *
What is the activity level at your job? *

none(seated only) Moderate (light activity such as walking) High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights? *
How often do you travel? *

Rarely A few times a year A few times a month Weekly

How would you rate the stress of your job? *

	1	2	3	4	5	6	7	8	9	10

1 is No or little stress, 10 is Overwhelming stress/verge of nervous breakdown

How would you rate the stress of your lifestyle? *

	1	2	3	4	5	6	7	8	9	10

1 is No or little stress, 10 is Overwhelming stress/verge of nervous breakdown

PAR-Q
Has your doctor ever said you have a heart condition? *

yes no
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *

yes no
Are you currently taking prescribed medications for a chronic medical condition? *

yes no
If yes to the previous question, please list your medications and how long you have been taking them.
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *

yes no
If yes to the above question, please explain the condition.
Has your doctor ever said you should only do medically supervised physical activity *

yes no
Health and Medical
Are you under the care of a physician, chiropractor, or other health care professional at this time for any reason? *

Yes No
If Yes to the question above, please list reason here.
Please list any injuries or surgeries you have had in the past five years. Enter none if none. *
Do any diseases run in your family? *

Yes No
If yes to the above question, please explain.
Do you suffer from or have a history of: *

Diabetes Type 1 Diabetes Type 2 Asthma High blood pressure Low blood pressure Heart attack Bypass or cardiac surgery Chest discomfort with exertion Rapid or runaway heartbeat Skipped heartbeat Shortness of breath with or without exercise Fainting or light-headedness Pulmonary disease or disorder Stroke High cholesterol Recent hospitalizations Orthopedic problems, including arthritis
Are you a current cigarette smoker? *

Yes No
If yes, how many cigarettes or ecigs per day?
Do you drink caffeinated drinks? *

Yes No
If yes, what and how many per day?
Do you drink alcohol? *

Yes No
If yes, how many glasses per day?
Do you have any pain or issues in your: *

Head/Neck Upper Back Shoulders Arm/Elbow Wrist/Hands Lower Back Hips/Pelvis Thigh/Knees Hernia
If yes, please explain.
Are you on any specific food/diet plan at this time? *

Yes No
If yes, please explain.
Have you had any recent weight gain or loss? *

Yes No
If yes, please explain:
Please list any dietary supplements you take here (protein powder, creatine, B12, etc). Enter none if none. *
Please list any allergies you have here. Enter none if none. *

Please rate how you feel your current nutritional habits are *

	1	2	3	4	5	6	7	8	9	10

1 is I don't worry about what I eat, I just eat whatever, wherever., 10 is I am very conscious of my food choices and eat whole foods fruits, and vegetables, and limit my processed food intake.

Goals
Which of the following goals best fit in with your goals for your training (select all that apply)? *

Appearance/Aesthetics Cardiovascular Endurance Flexibility Health (General) Muscular Definition Muscular Size Muscular Strength/Power Self-esteem/Confidence Speed Sports Performance Stress Reduction Weight Loss Posture
What are the top three goals you want to accomplish, in order of importance? *
What possible personal barriers do you feel are keeping you from reaching your nutritional and fitness goals? *

Lack of motivation Time Self Conscious Lack of equipment Lack of Results Hitting A Plateau Money Not knowing where/how to begin
How often are you willing to train per week to reach goals? *
Training and Exercise History
Do you have a membership at a commercial gym? *

Yes No
If yes, what gym?
What equipment do you have access to at home?

Dumbbells Barbells Weight Bench Aerobic Machines (treadmill, elliptical, stationary bike, rower, etc) Weight Machines Cable Weights Resistance Bands Bosu Ball Kettlebells Suspension Straps Punching Bag Stability Ball Pilates Reformer
Do you currently exercise on a regular basis? *

Yes No
If yes, how many days a week?
How long is each session in minutes?
Describe your exercise routine:
Have you trained with a personal trainer before? *

Yes No
If yes, was your previous experience negative or positive? Why?
Describe what you expect of me as your fitness coach. *
Mental Readiness/Personality

Please rate your mental readiness to make changes to reach your goal. *

	1	2	3	4	5	6	7	8	9	10

1 is I am not ready to make any changes. , 10 is I'm ready to make any lifestyle changes to reach my goals!

Please rate your motivational level to do what it takes to reach your goal. *

	1	2	3	4	5	6	7	8	9	10

1 is I have no motivation to change my life., 10 is I'm ready to make any lifestyle changes to reach my goals!

What motivates you?

Need a strong motivator to push you to exercise You like to be informed about your program and how it is going to lead you to your goals Like to try new things if they are effective Willing to push past your comfort level to reach your goals f I feel things are really hard I tend to back off Need to be held accountable for what I am doing Being sore the day after a workout tells me my workouts are working
Fitness with Jazzy Informed Consent Form
I, {fullName20}, give my consent to participate in the physical fitness evaluation program FITNESS BUSINESS NAME, conducted by TRAINER NAMES (hereinafter "The Trainers"). Benefits Participation in a regular program of physical activity has been shown to produce positive changes in a number of organ systmes. These changes include increased work capacity, improved cardiovascular efficiency, and increased muscualr stregnth, flexibility,power and endurance. Risks I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains, etc) and the cardiorespiratory system (dizziness, discomfort in breathing, heart attack, etc). I hereby certify I know of no medical problem (except those noted on this form) that would increase my risk of illness and injury as a result of participation in a regular exercise program. Testing and Evaluation Results I understand I will undergo initial testing to determine my current physical fitness status. The testing will consist of, in part or in whole, a health, medical, and lifestyle questionairre, a cardiovascular fitness test (bicycle, step, run, walk, or similar), and testing for muscular fitness and body composition. I further understand such screening is intended to provide The Trainers with essential information used in the development of individual fitness programs. I understnad my individual results will be made available only to me. I also understand the testing is not intended to replace any other medical test or the services of a physician. I will be provided a copy of all test results. I may share the results with whomever I please, including my personal physician. By signing this consent form, I understand I am personally responsible for my actions during my tenure with The Trainers and I waive the responsibility of this center if I should incur any injury as a result of my negligence.
I agree to the above terms and conditions! *

Yes No
Client Signature *

Clear
Today's Date *

Month Day Year
Date
Ftiness with Jazzy Liability Waiver I, {fullName20}, hereby agree that by signing this document, I consent to waive certain legal rights, including the right to sue the following party, and, if applicable, its owners, trainers, representatives, and facilities from any physical, material, tangible or intangible, loss or damages that may happen to me during my participation in any of the fitness services (hereinafter, "Fitness Services") undertaken while under their instruction or thereafter: FITNESS BUSINESS NAME OR TRAINER NAME (the "Fitness Provider"). I will be voluntarily participating in the Fitness Services that will be conducted by the Fitness Provider. These Fitness Services may include, but are not be limited to, the following: Resistance TrainingAerobic TrainingInterval/HIIT TrainingPlyometricsSport Specific TrainingFlexibility TrainingEndurance Training
A check mark below indicate I have read, agree with and understand the following: *

It is my responsibility to consult a physician before participating in this or any fitness program and I affirm that I have no medical conditions that would restrict me from participating in any of the Fitness Services. I agree to hold the Fitness Provider, and if applicable, its owners, trainers, and representatives, harmless from any damage, whether tangible or intangible, that may happen to me while participating in the Fitness Services. Such injuries may include, but are not limited to, muscle strains, muscle sprains, muscle spasms, heart attacks, raised blood pressure, and broken, fractured, or dislocated bones. I agree that the Fitness Provider offers the Fitness Services with no guarantee of results. I agree that I am solely responsible to maintain the diet and fitness regime appropriate for my level of health and stamina, and I agree that any results that occur, whether positive or negative, are the effects of my own personal choices. I agree that participation in the Fitness Services is not a replacement for actual medical care, and that if I do experience medical issues, I will contact my doctor immediately. I agree and verify that all of the information that I have given the Fitness Provider and its representatives is accurate, up-to-date, and without the omission of any known medical issues. I agree and verify that If I have omitted any necessary personal information, whether knowingly or unknowingly, I will hold the Fitness Provider harmless against all liability for any damages that may occur to myself or to others because of my actions or inactions. I agree to keep the Fitness Provider apprised of any changes or upcoming changes concerning my physical health and personal information. I understand and agree that it is my responsibility to let the Fitness Provider know if I find myself in any pain or discomfort before, after, or during the Fitness Services. If I do require medical treatment or attention while or after participating in the Fitness Services, I agree that the medical costs are mine and mine alone and hold the Fitness Provider blameless from any charges, fees, or costs that my conditions may incur.
This Fitness Services Waiver will bind and be enforceable against me and all of my personal representatives. I agree that this Fitness Services Waiver should be enforceable to the fullest extent of the law, and if any portion is held invalid, the remainder should continue in full legal force and effect. I specifically acknowledge and agree that this document is not intended to be a general release, which would be limited under some state and local laws. This Fitness Services Waiver shall be construed and interpreted as broadly as possible in the applicable jurisdiction. ASSUMPTION OF RISK. I understand and am aware that my participation in the Fitness Services involves risks. These risks may lead to tangible or intangible harm, and I agree that they may result not only from my own actions but also from the actions of others. With the knowledge and understanding of these risks, I choose, of my own will and volition, to continue participating in the Fitness Services. I am also aware that there are risks that I may not have considered, yet I waive my right to any claims that may occur from these unconsidered risks and I choose, of my own will and volition, to participate in the Fitness Services. COVENANT NOT TO SUE. I will not start any lawsuit or other court action against the Fitness Provider, nor will I join any such proceeding, including any claim for money damages. I acknowledge and agree that I am entering a covenant not to sue the Fitness Provider in any capacity, including to hold the Fitness Provider liable for any injury, loss, or damage sustained by me or my property, even if it is due to the Fitness Provider's negligence or omission. I also waive the right of any of my insurers' to make any such claim. INDEMNIFICATION: I agree to defend and indemnify the Fitness Provider and any of its affiliates (if applicable) and hold them harmless against any and all legal claims and demands, including reasonable attorney's fees, which may arise from or relate to my use or misuse of the Fitness Services or my conduct or actions. I agree that the Fitness Provider shall be able to select its own legal counsel and may participate in its own defense, if desired. REPRESENTATION: I am over 18 (eighteen) years of age, and am medically and physically able to participate in the Fitness Services. GOVERNING LAW: This Fitness Services Waiver shall be governed by and construed in accordance with the internal laws of Ohio without giving effect to any choice or conflict of law provision or rule. Each party irrevocably submits to the exclusive jurisdiction and venue of the federal and state courts located in the following county in any legal suit, action, or proceeding arising out of or based upon this Fitness Services Waiver: Cuyahoga County. I have read the above Fitness Services Waiver fully and I understand and agree to its contents. I understand and agree that by signing this Fitness Services Waiver I forfeit any right, claim, or ability to hold the Fitness Provider responsible for any tangible or intangible damages, loss of property, or loss of life that may occur during or after my use of the facilities and participation in the Fitness Services.
Client Signature *

Clear
Today's Date *

Month Day Year
Date
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Fitness with Jazzy

Client Intake Form

Lifestyle Information

PAR-Q

Health and Medical

Goals

Training and Exercise History

Mental Readiness/Personality