Health & Fitness Questionnaire

Please complete at least 2 days prior to your Consultation. All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to helping your trainer develop a program that addresses your needs, goals and interests safely. Please provide 24 hours notice if you need to cancel or reschedule your appointment.

Address
Address
Phone
Phone
Date of Birth
Date of Birth
Begin Questionaire
Has your doctor ever said that you have a heart condition and recommended 
only medically supervised physical activity?
Do you frequently have pains in your chest when you perform physical activity?
Have you had chest pain when you were not doing physical activity?
Do you lose your balance due to dizziness or do you ever lose consciousness?
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.)?
Are you pregnant now or have given birth within the last 6 months?
Yes No NA
Have you had a recent surgery?
Do you take any medications, either prescription or non-prescription, on a regular basis? *
Lifestyle Related Questions
Do you smoke?
Do you drink alcohol?
Describe your job
Fitness History
Nutrition Related Questions
Do you skip meals?
Do you eat breakfast?
Do you eat late at night?
Do you feel drops in your energy levels throughout the day?
Are you currently or have you ever taken a multivitamin or any other food supplements?
Exercise Related Questions: Skip to next section if you are presently inactive.

Goal Setting
Where do you rate health in your life?
 How committed are you to achieving your fitness goals?
Miscellaneous Questions:

How did you hear about us?  Please check that which applies.

Why did you choose to train with Powerhouse instead of another organization?  Please check that which applies.

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.

Today's Date *
Today's Date