Cover Sheet and Goals

New Client Forms

Basics, Goals, Health Questionnaire, Payment Agreement and Release of Liability
Name

First NameLast Name
Date

MonthDayYear
Date
Height
Weight
Personal Goals
Fitness Goals

Name

First NameLast Name
Please list any medical conditions, either past or ongoing, whether taking medication for or not (i.e high blood pressure, diabetes, thyroid dysfunction…):
Please list any major medical procedures, surgeries or injuries:
Please provide a complete list of any medications or supplements you are taking including prescription medication, over the counter medications, vitamins or supplements. Please include even if only taken occasionally.
Do you currently follow any special diet?
Do you currently smoke?
Do you currently engage in any form of exercise? Yes / No. If yes, please provide type of activity and frequency performed.
Are you currently receiving physical therapy?
Do you have a current primary medical practitioner? Yes / No. If yes, please list full name of practitioner.
Are you currently under any activity restrictions as imposed by your primary medical practitioner? Yes / No. If yes, please specify below.
Please provide the name and primary phone number for at least one emergency contact.
I attest that the above information that I have provided is true and correct to the best of my knowledge.
I attest that I have not chosen to hide or not disclose any information relevant to my health that may impact my safety.
I understand that it is my responsibility to disclose any changes to my health including conditions, medications or planned procedures.
I understand that I am willingly and voluntarily participating in an exercise program designed by my personal trainer.
I assume full liability of any illness, injury or exacerbation of any medical condition that may arise from the exercise program as set forth by my personal trainer.
I release Sara Jorgensen, personal trainer, from any liability related to any illness injury or exacerbation that may occur during or as a result of our training sessions.
I understand that my personal health information is confidential.
I grant Sara Jorgensen permission to share any personal health information with my doctors or other individuals as listed above.
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MonthDayYear
Date

Name

First NameLast Name
I release Sara Jorgensen of any liability related to any accident, injury, illness or death that may occur during or related to our personal training sessions. I understand that I am voluntarily participating in these sessions and the physical activity as set forth by the above stated personal trainer and that by signing this waiver I am fully aware of the risks, both known and unknown that may arise from this activity. I waive the right to legal recourse should any accident, illness, injury or death occur. Additionally, I waive the right on behalf of any family, next of kin or legal agents to pursue any legal recourse should any of the above stated negative events occur. I attest that I have read this form in its entirety and am signing it of my own volition.
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Date

Name

First NameLast Name
I agree to pay Sara Jorgensen the full amount agreed upon prior to commencing training sessions in exchange for personal training services and understand that services may be terminated if payment is not rendered at the time of service.
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New Client Forms