Personal Trainer Client Intake and Liability Form

Train With Cyndee

Coach Cyndee
Client Intake Form
Full Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Age*
years
Height*
Inches
Weight*
lb
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Email*

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

Phone callEmailTextMessengerOther
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?*

RarelyA few times a yearA few times a monthWeekly

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

What are your hobbies, or what do you like to do in your spare time?*
PAR-Q
Has your doctor ever said you have a heart condition?*

yesno
Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?*

yesno
Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?*

yesno
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*

yesno
If yes to the above question, please list the condition(s) here.
Are you currently taking prescribed medications for a chronic medical condition?*

yesno
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?*

yesno
If yes to the above question, please explain the condition.
Has your doctor ever said you should only do medically supervised physical activity*

yesno
Health and Medical
Are you under the care of a physician, chiropractor, or other health care professional at this time for any reason?*

YesNo
If Yes to the question above, please list reason here.
If you are on any medications not previously mentioned, including multivitamins,please list them here, including how long you have been taking them. Enter none if none.*
If you have any diagnosed health problems not previously mentioned, please list the condition(s) here. Enter none if none.*
Please list any injuries or surgeries you have had in the past five years. Enter none if none.*
Has anyone of your immediate family developed heart disease before the age of 60?*

YesNo
Do any diseases run in your family?*

YesNo
If yes to the above question, please explain.
Do you suffer from or have a history of:*

Diabetes Type 1Diabetes Type 2AsthmaHigh blood pressureLow blood pressureHeart attackBypass or cardiac surgeryChest discomfort with exertionRapid or runaway heartbeatSkipped heartbeatShortness of breath with or without exerciseFainting or light-headednessPulmonary disease or disorderStrokeHigh cholesterolRecent hospitalizationsOrthopedic problems, including arthritisOther
If yes to any of the above, please explain here.
Are you a current cigarette smoker?*

YesNo
If yes, how many cigarettes or ecigs per day?
Do you drink caffeinated drinks?*

YesNo
If yes, what and how many per day?
Do you drink alcohol?*

YesNo
If yes, how many glasses per day?
Do you have any pain or issues in your:*

Head/NeckUpper BackShouldersArm/ElbowWrist/HandsLower BackHips/PelvisThigh/KneesHerniaOther
If yes, please explain.
Are you on any specific food/diet plan at this time?*

YesNo
If yes, please explain.
Have you had any recent weight gain or loss?*

YesNo
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.

Is there any reason not mentioned why you should not follow a regular exercise program? (Please remember it is your responsibility to you to consult with a physician before starting an exercise routine)*

YesNo
If yes, please explain:
Goals
Which of the following goals best fit in with your goals for your training (select all that apply)?*

Appearance/AestheticsCardiovascular EnduranceFlexibilityHealth (General)Muscular DefinitionMuscular SizeMuscular Strength/PowerSelf-esteem/ConfidenceSpeedSports PerformanceStress ReductionWeight LossPostureOther
What are the top three goals you want to accomplish, in order of importance?*
Explain why these three goals are most important to you.*
What possible personal barriers do you feel are keeping you from reaching your nutritional and fitness goals?*

Lack of motivationTimeSelf ConsciousLack of equipmentLack of ResultsHitting A PlateauMoneyNot knowing where/how to beginOther
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?*

YesNo
If yes, what gym?
What equipment do you have access to at home?

DumbbellsBarbellsWeight BenchAerobic Machines (treadmill, elliptical, stationary bike, rower, etc)Weight MachinesCable WeightsResistance BandsBosu BallKettlebellsSuspension StrapsPunching BagStability BallPilates ReformerOther
Do you currently exercise on a regular basis?*

YesNo
If yes, how many days a week?
How long is each session in minutes?
Describe your exercise routine:
Do you currently participate in any competitive sports?*

YesNo
If yes, what sports and how often?
Have you trained with a personal trainer before?*

YesNo
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 exerciseYou like to be informed about your program and how it is going to lead you to your goalsLike to try new things if they are effectiveWilling to push past your comfort level to reach your goalsf I feel things are really hard I tend to back offNeed to be held accountable for what I am doingBeing sore the day after a workout tells me my workouts are workingOther
Can you accept responsibility for the way your body is today and understand that, while your old habits don't make you a bad person, they still need to be changed?

YesNo
Train With Cyndee

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!*

YesNo
Client Signature*

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Train With Cyndee

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: Train With Cyndee

I will be voluntarily participating in the Fitness Services that will be conducted by Cyndee Platko. These Fitness Services may include, but are not be limited to, the following:

Resistance Training
Aerobic Training
Interval/HIIT Training
Plyometrics
Sport Specific Training
Flexibility Training
Endurance 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 activities.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*

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Train With Cyndee

Client Intake Form

Lifestyle Information

PAR-Q

Health and Medical

Goals

Training and Exercise History

Mental Readiness/Personality