Thin Line Fitness of Ohio, LLC

  • Thin Line Fitness of Ohio, LLC

    2430 Mill Street Millersport, OH 43046
  • Format: (000) 000-0000.
  • Are you 18 years or older?*
  • Format: (000) 000-0000.

  • Medical Questionnaire

    Please Complete Below Medical Related Questions
  • Format: (000) 000-0000.
  • 4. Answer to question #3:
  • 7. Answer to question number #6
  • 9. Answer to question #8
  • 10. Are you used to vigorous execise?
  • 11. Has a doctor diagnosed you with a heart condition or heart disease?
  • 12. Have you ever had had angina pectoris, sharp pain, or heavy pressure in your chest as a result of exercise, walking, or other physical activity such as climbing stairs? (Not including the normal out of breath feeling that results from normal activity)
  • 13. Do you experience any sharp pain or extreme tightness in your chest in cold temperatures?
  • 14. Have you ever experienced rapid heart beat or palpitations?
  • 15. Have you ever had a real or suspected heart attack, coronary occlusion, myocardial infarction, coronary insufficiency, or thrombosis?
  • 16. Have you ever had rheumatic fever?
  • 17. Do you have or have you had diabetes, hypertension, or high blood pressure?
  • 18. Have you ever or do you take medications or been on a special diet to lower your cholesterol?
  • 19. Have you ever take digitalis, quinine, or any other drug for your heart?
  • 20. Have you ever taken nitroglycerine or any other tablets for chest pain?
  • 21. Are you overweight?
  • 22. Do you suffer from anxiety or depression?
  • 23. Do you drink alcoholic beverages? If so, how many per day and what kind?
  • 25. Do you drink caffeinated beverages? If so, how many per day and what kind?
  • 27. Do you use tobacco? If so, how many/much per day and what type?
  • 29. Do you have a physical condition, impairment or disability, including a joint or muscle problem, that should be considered before you begin a nutrition program?
  • 30. Do you exercise fewer than three (3) times a week?
  • 31. What is your occupational stress level?
  • 32. What is your stress level at home?
  • 33. What is your energy level?
  • 34. Do you have anemia?
  • 35. Do you have a gastrointestinall disorder?
  • 36. Do you have hypoglycemia?
  • 37. Do you have thyroid disorder?
  • 38. Are you under pre or postnatal care?
  • 39. Do you have a history of high cholesterol?
  • 40. Do you have hyperlipidemia?
  • 41. Have you ever had a stroke?
  • 42. Are you on any specific food/diet plan? If yes please provide a copy and who provided it.
  • 43. Do you take any dietary supplements? If yes please list
  • 45. Have you experienced a recent a weight gain or loss? If yes, over what time and how much?
  • 47. Do you have any dietary dislikes? Specifically fruits, veggies, grains, beans, meats, or dairy? If yes please list
  • 50. How would you describe your current work and exercise habits?
  • 51. Is there any reason not mentioned why you should not follow a regular exercise program? If yes, please explain

  • Exercise Questionnaire

    Please complete below questions pertaining to your exercise history
  • 1. Are you currently involved in a regular exercise program?
  • 2. Do you regularly walk or run 1 or more miles continuously? If yes, what is the average number of miles you cover in a workout? What is your average time per mile?
  • 4. Do you lift weights?
  • 5. Are you involved in an aerobic program?
  • 6. Do you frequently compete in competitive sports? If yes, which one(s)? If not, what sports interest you?

  • Family History Questionnaire

    Please answer the below questions regarding Family History
  • 1. Asthma OR Respiratory/Pulmonary Conditions
  • 3. Type I or Type II Diabetes
  • 5. Petite Mall Epilepsy or Grand Mal Epilepsy
  • 7. Osteoporosis
  • 9. Hypertension or High Blood Pressure
  • 11. Stroke
  • 13. Has any blood relative (Parent, Sibling, First Cousin) had a heart attack or coronary artery disease before the age of 50?

  • Goals and Other Get to Know You Information

    Please complete the below questions
  • 3. Do you have any interest if our gym would have 24 hour access to members?

  • Liability Waiver

    I am voluntarily participating in physical exercise that can be strenuous and subject to risk of serious injury during PRIVATE OR GROUP TRAINING. Thin Line Fitness of Ohio, LLC urges you to obtain a physical examination from a doctor before beginning any exercise or training program. You agree that by participating in these physical exercise sessions or personal training activities, is at your own risk. I recognize that exercise is not without some risk to the musculoskeletal system (e.g. sprain, strain) and cardiorespiratory system (e.g. dizziness, fainting, abnormal heartbeat, discomfort in breathing, abnormal blood pressure response, and in rare instances, heart attack or stroke).  I acknowledge that not all risks can be known in advance.

    I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, “Releasor,” “I” or “me”, which terms shall also include Releasor’s parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity.

    I HEREBY release and forever discharge Thin Line Fitness of Ohio, LLC, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively “Releasees”), from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity.

    I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney fees and any related costs.

    I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize Thin Line Fitness of Ohio, LLC to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. 

    I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. In the event that any damage to equipment, field or facilities occurs as a result of my or my family’s or my agent’s willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness. Both participant and Thin Line Fitness of Ohio, LLC agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted altering or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.

  • AGREE*

  • Photo/Video Release

    I hereby grant the Thin Line Fitness of Ohio, LLC permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web- based publications, without payment or other consideration.

    I understand and agree that all photos will become the property of the Thin Line Fitness of Ohio, LLC and will not be returned.

    I hereby irrevocably authorize the Thin Line Fitness of Ohio, LLC to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any 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 the photo.

    I hereby hold harmless, release, and forever discharge the Thin Line Fitness of Ohio, LLC from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

    I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT:

  • AGREE*
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