Personal Training Form

1
Has your doctor ever said that you have a heart condition and recommended only medically supervised activity
YESNO
2
Do you frequently have pains in your chest when you perform physical activity?
YESNO
3
Do you lose your balance due to dizziness or do you ever lose consciousness?
YESNO
4
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?
YESNO
5
Are you pregnant now or have given birth within the last 6 months?
YESNO
6
Have you had a recent surgery?
YESNO
7
Have you had chest pain when you were not doing physical activity?
YESNO
8
Do you take any medications, either prescription or non-prescription, on a regular basis? If you answered yes, what is the medication for? How does this medication affect your ability to exercise or achieve your fitness goals? Answer NA if does not apply
9
On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)
10
How often do you take part in physical exercise?Select all that apply
5-7x/week
3-4x/week
1-2x/week
Don't have a consistent schedule
11
If your participation is lower than you would like it to be, what are the reasons?
Lack of Interest
Illness/Injury
Lack of Time
Other
12
If you could design your own exercise program, what would an ideal training week look like to you? Please be specific. List your favorite activities, rest days, time spent etc.
Huge
Large
Normal
Small
Ok
Ok
13
How can a Personal Trainer help you? Please check that which applies.Choose all that apply
Lose Body Fat
Develop Muscle Tone
Nutrition Education
Start an Exercise Program
Design a more advanced program
Sports Specific Training
Advanced program
Increase Muscle Size
Motivation
Other
14
   I, First Name     Last Name    , wish to participate in the exercise and training program offered by AM Wellness. I understand there are inherent risks in participating in a program of strenuous exercise. I agree that AM Wellness, LLC shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge AM Wellness, LLC, its owners, employees, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or
claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators and assigns.

I have read and understand this term(initial or sign): Signature
15
I certify that the answers to the questions outlined on the PAR-Q form are true
and complete to the best of my knowledge. I acknowledge that medical
clearance is required if I have answered “Yes” to any of the questions on the
PAR-Q form. I understand and agree that it is my responsibility to inform my
Personal Trainer of any conditions or changes in my health, now and on going,
which might affect my ability to exercise safely and with minimal risk of injury.

I have read and understand this term(initial or sign): Signature
16
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 my Personal Trainer.

I have read and understand this term(initial or sign): Signature
17
I understand the results of any fitness program cannot be guaranteed and my
progress depends on my effort and cooperation in and outside of the sessions.

I have read and understand this term(initial or sign): Signature
18
I understand that the usage of any nutritional supplements is done under my own
will and has not been prescribed by my Personal Trainer.

I have read and understand this term(initial or sign): Signature
19
PERSONAL TRAININGSESSIONS ARE 1 HR LONG. SESSIONS MUST BE USED WITHIN A YEAR OR THEY WILL EXPIRE
1 SESSION (PAY AS YOU GO) - $100/HR
5 SESSIONS - $450 (SAVE $50)
10 SESSIONS - $870 (SAVE $130)
20 SESSIONS - $1700 (SAVE $300)
30 SESSIONS - $2340 (SAVE $660)
40 SESSIONS - $3000 (SAVE $1000)
Should be Empty: