Health History Waiver Form

Health History Waiver Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Have you had, or do you presently have any of the following? (Check if yes)

Heart AttackAny kind of heart disease or surgeryDiabetesPrediabetesHigh blood pressureLow blood pressureKidney diseaseHigh cholesterolLung diseaseSeizuresCancerRecent operationFainting or dizzinessChest painsPalpitations or tachycardia (Unusual strong or rapid heartbeat)Muscle or joint problems (e.g., back, knee)Edema (Swelling of ankles)Pain, discomfort in the chest, neck, jaw, arms or other areas.Unusual fatigue or shortness of breath at rest or with activity.Temporary loss of clear vision or speech or short-term numbness or weakness in one side, arm or leg of the body.Shortness of breath while lying down, at night or comes on suddenly.Intermittent claudication (calf cramping)Other
Please describe “Other”
1) Do you participate in a regular exercise program currently ?
2) Have you ever preformed strength training exercise in the past?
3) What are you eating habits? Breakfast, Lunch, Dinner?
4) What are your fitness and wellness goals?
How many days per week are you willing to commit to exercise and wellness?
What is your height?
What is your weight?
Favorite foods?
What is your goal weight?
Consent to Participate

I, the undersigned, acknowledge that I have voluntarily chosen to participate in personal training and wellness services provided by Zupp Fitness and Wellness. I understand that these services may involve physical activity that can be strenuous and may pose the risk of injury. I affirm that I am in good health and have no known medical conditions that would prevent my participation in these activities.

I hereby consent to the collection of my health history and other personal information as necessary for my training program. I understand that this information will be kept confidential and used only for the purpose of providing personalized training services.

I have read this consent form, and I understand its content. I am aware of the risks involved in participating in personal training and wellness services, and I accept those risks.
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