The Fit Academy Training Consultation Questionnaire

Personal Training Consultation Questionnaire
Full Name

First NameLast Name
Gender

MaleFemale
Date of Birth

MonthDayYear
Age
years
Height
cm
Weight
LBs
What do you do for a living?
Whats 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
Please list the physical activities that you participate in outside of the gym and outside of work.:
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?

YesNo
Has anyone of your immediate family developed heart disease before the age of 60?

YesNo
Do any diseases run in your family?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
Please list:
Are you a current cigarette smoker?

YesNo
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
Please rate your readiness for change.

12345678910
What following goals does best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?
Why?

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train a week to reach your goal?
Please rate your motivational level to do what it takes for reach your goal.

12345678910
Are you currently excersising regulary (at least 3x per week)?

YesNo
Have you trained with a personal trainer before?

YesNo
What kind of training did you do?
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening
How often do you want to do Personal Training a week?
Please Choose
What are your expectations on me as your Personal Trainer?
Monthly Package Options (45 days to complete sessions)

4 Sessions a week $3753 Sessions a week $2752 Sessions a week $2201 Session a week $125
1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!

YesNo
Phone Number
Please enter a valid phone number. We will be in contact shortly.

THE FIT ACADEMY - PARTICIPATION WAIVER AND RELEASE FORM
The Fit Academy

1437 S. Main Street

Farmville,Va 23901

TheFitAcademyVa@gmail.com | 434-392-3308

WAIVER AND RELEASE OF LIABILITY

In consideration of being allowed to participate in any way in the fitness programs, related events, and activities of The Fit Academy ("Facility"), I, acknowledge, appreciate, and agree that:

Risk of Injury: The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death. While particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist.
Fitness Suitability: I have been advised to consult with a physician before commencing any exercise program or diet. I represent that I am in good physical condition and have no disability, impairment, or ailment preventing me from engaging in active or passive exercise or which will be detrimental or inimical to my health, safety, comfort, or physical condition if I do engage or participate.
Assumption of Risk: I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases or others, and assume full responsibility for my participation. I understand all risks associated with exercise and the fit academy will not be liable for any of the risks associated with exercising.
Compliance with Instructions: I agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring it to the attention of the nearest official immediately.
Release and Indemnity: I, for myself and on behalf of my heirs, assigns, personal representatives, and next of kin, hereby release and hold harmless The Fit Academy, its officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (“Releases”), with respect to any and all injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releases or otherwise, to the fullest extent permitted by law.
Photography/Video Release: I consent to all forms of media and communication, photography, and video while at The Fit Academy. I understand these may be used for promotional, educational, and/or informational purposes by The Fit Academy. I agree that all rights to these images and footage belong to The Fit Academy.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, and fully understand its terms. I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

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Personal Training Consultation Questionnaire