Date of Birth
Date of Birth
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.)?
If you have marked YES to any of the above, please elaborate below:
What is the medication for?
Lifestyle Related Questions
If yes, how much?
If yes, how much?
How many hours do you regularly sleep at night?
On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)?
When were you in the best shape of your life?
When did you first start thinking about getting in shape?
What if anything stopped you in the past?
On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?
Nutrition Related Questions
On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?
How many times a day do you usually eat (including snacks)?
How many glasses of water do you consume daily?
If yes, list all supplements.
Exercise Related Questions: Skip to next section if you are presently inactive.
How often do you take part in physical exercise?
How long have you been consistently active for?
What activities are you presently involved in?
How can a personal trainer help you?
What is your short term goal?
What is your long term goal?
If you were referred to us, who told you about our services?
PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT - READ
I wish to participate in the exercise and training program offered by Powerhouse Gym Downtown Santa Rosa. I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. I agree that Powerhouse gym 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 Powerhouse Gym, 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 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 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 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 understand that Powerhouse Gym bills its Personal Training clients on a pre-pay basis. Once my trainer and I have decided upon the type of training package and payment plan I will purchase, payment must be made before the sessions are conducted. Credit cards, cash and checks made payable to Powerhouse Gym are all accepted. I understand that all Personal Training sessions are non-refundable.
I understand that Powerhouse Gym operates on a scheduled appointment basis for all Private Training sessions and thus, requires that I provide 24 hours notice when canceling an appointment. No charge will be levied should I cancel with MORE than 24 hours notice given. Should I cancel a session without 24 hours prior notice, I will be charged in full for that session. I understand that Powerhouse Gym recommends that all cancelled sessions be rescheduled to ensure consistency and fitness progress.
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 understand that Powerhouse Gym photographs many of their client events/sessions and I provide written approval for them to use these pictures for promotional purposes.
I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.
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