Health Questionnaire & forms Health questionnaire Name * First Name Last Name Email * Gender Height Weight Physician Name and Phone # Emergency Contact and Phone # What exercise activities do you currently take part in (e.g running, weightlifting, group exercise, etc.)? How many days per week do you get at least 60 minutes of moderate-intensity exercise? On a scale of 0 to 10, how important is weigh loss to you as a fitness goal? On a scale of 0 to 10, how important is muscle gain to you as a fitness goal? On a scale of 0 to 10, how important is sports performance to you as a fitness goal? On a scale of 0 to 10, how important is health improvement to you as a fitness goal? On a scale of 0 to 10, do you consider your overall diet to be healthy? Are you currently following any kind of diet? If so, what diet and for what reason(s)? How would you rank your daily salt intake: low, medium, or high? How would you rank your daily sugar intake: low, medium, or high? How would you rank your daily fat intake: low, medium, or high? On a scale of 0 to 10, how effectively are you able to control your temptations for junk food? How many alcoholic drinks do you consume per week? Do you consume caffeinated beverages such as coffee, tea, soda, and/or energy drinks? How many per week? Do you feel like you get enough sleep and wake up feeling rested each day? On a scale of 0 to 10, how would you rate your average level of stress? What techniques do you currently use to manage your stress levels? Do you smoke tobacco or use a vaporizer alternative? What is your occupation? Does your occupation require extended periods of sitting? (If YES, please explain.) Does your occupation require repetitive movements? (If YES, please explain.) Does your occupation require you to wear shoes with a heel (e.g., dress shoes, work boots)? Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.) Do you have any additional hobbies (gardening, fishing, music, etc.)? (If YES, please explain.) Please list out any past musculoskeletal injuries: Please list out any past surgeries: If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance from a doctor to return to physical activity? If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance from a doctor to return to physical activity? Are you on any medications, and if so, have you received clearance from your doctor to take part in physical activity? Additional Notes Thank you! Personal training liability waiver & testimonial, social media , and photo release form Email * I [Client’s first and last name] hereby affirm that I am voluntarily starting a course of instruction in physical fitness and performance training which may include retreats, online sessions and other various activities with 1010 Living LLC (“Activity”). I am voluntarily participating in the Activity entirely at my own risk. In full consideration of the risk of injury while participating in the Activity, and for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily participate in this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity with 1010 Living LLC, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any kind of risks related to traveling to and from as well as participating the Activity, which may include, but are not limited to, physical or psychological injury, pain, suffering, illness disfigurement, temporary or permanent disability, economic or emotional loss, and death. I acknowledge that I have carefully read this form and fully understand that it is a release of liability. I expressly agree to release and discharge the trainer or instructor from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I may otherwise have to bring a legal action for personal injury or property damage. * In consideration of good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I, the undersigned, hereby grant to __________________(“Trainer”) and his/her agents the right to use my name, biographical information, photographs, images, story and/or testimonial, in whole or in part, and without restriction as to changes or alterations. The rights granted herein shall extend in perpetuity, unless revoked in writing to Trainer by me, throughout the world and for any purpose whatsoever, including without limitation for marketing and advertising purposes of Trainer, and in any and all media, including without limitation Trainer’s website. I acknowledge that Trainer has no obligation to return any photographs or images to me. I hereby RELEASE, WAIVE and FOREVER DISCHARGE any and all claims arising out of, or in connection with, such use by Trainer, including without limitation any and all claims for libel or invasion or privacy. I hereby warrant and represent that I am at least 18 years of age and have the right to contract in my own name. I have read the above Release and am fully familiar with the contents thereof. This Release contains the entire agreement between the parties hereto as to the subject matter contained herein. Thank you!
