• Client Intake Form

  • Gender*
  • Format: 0000000000.
  • What is the best way to contact you?

  • Lifestyle Information

  • What is the activity level at your job?*
  • How would you rate your quality of sleep at night?

  • Goals & Exercise History

  • What are your primary fitness goals? (select all that apply)*
  • What training style would best describe how you like / would like to train?
  • How many days a week do you plan to exercise?
  • How many days a week are you looking to train with a Personal Trainer?
  • What time of day do you prefer to train?
  • What possible personal barriers do you feel are keeping you from reaching your fitness goals?*
  • Do you currently participate in any competitive sports?*
  • Have you trained with a personal trainer before?*

  • HEALTH PAR-Q

  • Has your doctor ever said you have a heart condition?*
  • Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?*
  • Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?*
  • Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*
  • Are you currently taking prescribed medications for a chronic medical condition?*
  • 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?*
  • Has your doctor ever said you should only do medically supervised physical activity*

  • Health and Medical

  • Are you under the care of a physician, chiropractor, or other health care professional at this time for any reason?*
  • Has anyone of your immediate family developed heart disease before the age of 60?*
  • Do any diseases run in your family?*
  • Do you suffer from or have a history of:
  • Do you have any pain or issues in your:
  • Are you on any specific food/diet plan at this time?*
  • 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)*

  • Montana Ferguson Fitness

    Informed Consent Agreement

  • I give my consent to participate in physical fitness with Montana Ferguson Fitness, conducted by Montana Ferguson.

    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!*

  • Montana Ferguson Fitness

    Liability Waiver

  • 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.

  • I agree to the above terms and conditions!*
  • Today's Date*
     - -
  • Should be Empty: