NuLife Fitness Camp® Questionnaire

NULIFE FITNESS CAMP®

QUESTIONNAIRE
Client Information
Date*

MonthDayYear
Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Date
Age
Height*
Gender*
Employer & Occupation*
Note: if Self-employed name business. If student type "Student".
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone*
Secondary Phone
E-mail (please type "NONE" if applicable)*
example@example.com
Emergency contact (EC)*

First NameLast Name
EC Phone number*
EC Relationship*
How did you hear about NuLife Fitness Camp?*
Member Name
If you selected 'Member' as referral
All persons reproducing, redistributing, or making commercial use of this information are expected to adhere to the terms and conditions asserted by the copyright holder. Revised 1/2018

	Yes	No
Do you use any tobacco?

	Yes	No
Do you consume alcohol?

WAIVER/INFORMED CONSENT FORM FOR FITNESS TRAINING
I acknowledge that I have been informed of the need to obtain a physician’s examination and dietician’s approval prior to beginning this exercise/nutrition program.
I acknowledge that I have voluntarily chosen to participate in this program of progressive physical exercise, which can enhance musculoskeletal and cardio respiratory systems.
I fully understand that the personal training, exercise program may be strenuous and choose to participate completely voluntarily. I assume all risk, and accept all responsibility for my health and any resultant injury or mishap that may affect my well being or health in any way.
I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform the group fitness instructor. I give NuLife Fitness Camp® and its staff permission to seek emergency medical services for me should I become injured or ill with the understanding that I am responsible for any expenses incurred.
I understand that use my photographs or video images are property of NuLife Fitness Camp®. I understand that my image may be edited, copied, exhibited, published, or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image. Photographic and/or video recordings may also be used for the purpose of displaying results. By signing, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in public marketing setting.
By signing this document, I assume all risk for my health and well-being and hold harmless of any responsibility, the group fitness instructor, facility or any persons involved with this program or testing materials. In signing this document, I acknowledge being informed of the possible strenuous nature of the program. By signing this document, I voluntarily agree to participate in the nutrition and diet plan for this training. I also grant permission for use of photographs and videos as they are property of NuLife Fitness Camp®. This waiver and informed consent contract will automatically renew itself from month to month from the date of signature.
Signature
Full Name (Please Print)*

First NameMiddle NameLast Name
Signature*

Clear
Date*

MonthDayYear

All persons reproducing, redistributing, or making commercial use of this information are expected to adhere to the terms and conditions asserted by the copyright holder. Revised 1/2018
Should be Empty:

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel fain in your chest when you do physical activity?
n the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

NULIFE FITNESS CAMP®

Client Information

Personal Health History

Family Health History

Physical Activity Readiness Questionnaire (PAR-Q) and You

WAIVER/INFORMED CONSENT FORM FOR FITNESS TRAINING

Signature