ActivEdge Personal Training Evaluation

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Full Legal Name* This field is required.Please provide your full legal name below
First Name
Middle Name
Last Name
2
Preferred NamePlease provide your preferred name below
First Name
Last Name
3
Address* This field is required.Please provide your current mailing address below
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Primary Phone Number* This field is required.Please provide your current phone number below
Please enter a valid phone number.
5
Secondary Phone NumberPlease provide a secondary phone number below, if applicable
Please enter a valid phone number.
6
Emergency Contact* This field is required.Full Name, Phone, Relationship
7
Email* This field is required.Please provide an active email below, *this email will be used for MindBody account access, appointment Reminders, billing receipts, etc
example@example.com
8
Date of Birth* This field is required.Please provide legal date of birth below
Date
Month
Day
Year
9
How did you hear about us?Please provide how our business reached you
10
Personal Fitness Goals* This field is required.Examples- Overall improvement in strength, Endurance, Post-injury, Weight loss, etc.
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Current Medical/Injuries* This field is required.Please provide any medical conditions or physical injuries that would impact your future training
Huge
Large
Normal
Small
Ok
Ok
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Significant Past Medical/ Injury History* This field is required.Please provide past medical history and any injuries
Huge
Large
Normal
Small
Ok
Ok
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The Physical Activity Readiness Questionnaire--- PAR-QCommon sense is your best guide when you answer these questions. Please read the questions carefully and answer each on honestly: Answer Yes or No
14
Has your doctor ever stated that you have a heart condition and that you should only do physical activity recommended by a doctor?* This field is required.
YESNO
15
Do you feel pain in your chest when doing physical activity?* This field is required.
YESNO
16
In the past month, have you had chest pain when you were not doing physical activity?* This field is required.
YESNO
17
Do you lose your balance because of dizziness or do you ever lose consciousness?* This field is required.
YESNO
18
Do you have bone or joint problems (for example, back, knee, or hip) that could be made worse by a change in your physical activity?* This field is required.
YESNO
19
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?* This field is required.
YESNO
20
Do you know of any other reason why you should not do physical activity?* This field is required.
YESNO
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I have read , understood, and complete this PAR-Q questionnaire. Any questions I have were answered to my full satisfaction.* This field is required.
22
Have you ever been to a gym before?* This field is required.
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Current Fitness Level* This field is required.Rate on Scale (0-10) 0- Not fit at all 5- Moderately fit 10- Extremely fit
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Are you currently exercising?* This field is required.
YESNO
25
Have you played sports before/ currently playing sports? * This field is required.If YES, what sport(s)?
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If you answer YES to the previous question, how many years in the current sport, what position played or playing?
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Have you ever had a personal trainer before/ participated in personal training?* This field is required.
YESNO
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If you answered YES to the question below, please briefly explain your experience (for example, did you reach your goals?)*Have you ever had a personal trainer before/ participated in personal training?
29
What personal trainer would you prefer?* This field is required.
Male
Female
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Fitness Knowledge* This field is required.RATE ON SCALE (0-10) 0- NO KNOWLEDGE 5- SOME KNOWLEDGE OF NAMES, MOVEMENTS, EQUIPMENT 10- EXPERT KNOWLEDGE
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Waiver of Liability & Financial Policy

I hereby agree to voluntarily participate in the program(s) for which I am registered. I acknowledge that I am aware of ActivEdge Fitness & Sports Performance’s policy that participants who engage in physical activity should consult their physician(s) for approval. I also acknowledge that I have read and answered all medical history questions truthfully and to the best of my knowledge.

I agree to absolve ActivEdge Fitness & Sports Performance, Inc., and its owners, employees, and instructors of all liability for any accident, illness, or loss arising from my participation in the programs for which I am registered and hereby waive the right to claim damages or compensation for any such accident, illness, or loss arising from ActivEdge Fitness & Sports Performance, Inc., and its owners, employees, and instructors.

AE has a 12-hour cancellation policy. This is more generous of the typical 24 hour ploicy for most studios and physical therapy clinics, but we underestand that some things come up that make it difficult to cnacle in advance. Since our policy is only 12 hours, we hold firm to it and will bill you for the scheduled session if you have not notified staff. Please call, email, or go online to cancel ahead of time, or you will be charges for the session you missed.

I have read and understand these terms and this agreement.
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Signature* This field is required.Waiver of Liability & Financial Policy
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Please verify that you are human* This field is required.
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