Fitt By Stefan Sign-up Form

Client Information
Name*
First NameSurname
Date of Birth*
DayMonthYear
Date
Sex*
Marital Status
Education
Occupation
Position
Employer
Work Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Employer Contact Number
Please enter a valid phone number.
Email*
example@example.com
Contact Number*
Full Home Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
In Case of Emergency Contact Number*

Informed Consent
General Statement of Program Objectives and Procedures:
I understand that this personal training program may include exercises to build the cardio respiratory system (heart and lungs), the musculoskeletal system, (which involves muscular endurance, strength and overall flexibility), and to improve body composition (increasing muscle and bone and decreasing body fat) Exercise includes aerobic activities, such as walking, running, bicycle riding, rowing machine, group aerobics, swimming and other aerobic activities, weight lifting using dumbbells, machines and other equipment to improve muscular strength and endurance, as well as flexibility exercises to improve joint range of motion.
I Agree

Description of Potential Risks:
I understand that the reaction of the heart, lung, blood vessels as well as other systems to exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during the following exercise, which include abnormalities of blood pressure or heart attacks as well as other side effects. Use of weight lifting equipment and engaging in heavy body calisthenics may lead to musculoskeletal strains, pain and injury if adequate warm-up, gradual progression, and safety procedures are not consistently followed. I understand that my personal trainer (seller) shall not be liable for any damages arising from personal injuries sustained by client (buyer) while and during and/or from a personal training program does so at his/her own risk. Client (buyer) assumes full responsibilities for any injuries or damages which may occur during and/or after training.
I hereby fully and forever release and discharge personal trainer (seller), its assigns and agents from all claims, demands, damages, rights of action, present and future therein.
I understand and warrant, release and agree that I am in good physical condition and that I have no disability, impairment or ailment preventing me from engaging in active or passive exercise that will be detrimental to heart, safety, or comfort, or physical condition if I engage or participate (other than those items fully discussed on the health history form).
I state that I have had a recent physical checkup and have my personal physician’s permission to engage in aerobic and/or anaerobic conditioning.
I Agree

Description of Potential Benefits:
I understand that a program of regular exercise for the heart, lungs, muscles and joints has many benefits associated with it. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in physiological function and decrease in heart disease.
I have read the foregoing information and understand it. Any questions, which may have occurred, have been answered to my satisfaction.
I Agree

Tell Me More
Tell me more about your fitness goals?*
What exercise equipment do you currently have at your disposal?*
Do you have any injuries or medical conditions that I should be aware of?*

Body Under Construction
Starting Weight:
Height:
Motivation Level:
On a scale from 1 to 10 (10 being the highest level of motivation)
Activity Level:
How many days per week are you physically active?
Your Measurements:
How to take your measurements:
Chest: Use measuring tape, measure around the thorax at the nipple
line level underneath armpits and over the scapula.
Arm: Measure flexed and unflexed on the peak of your bicep.
Waist: Make the measurement around the slimmest part of your
abdomen.
Hips: Feel for the 2 bony structures pointing forward, measure
around the body on that line.
Quads: Measure around the upper-leg (mid leg) flexed and
unflexed.
Calf: measure around the widest part of your calf
Chest
Arm
Waist
Hips
Quad
Calf
Please upload photos of a full body view from the front, back and side (please avoid loose fitting clothes).
Cancelof

Medical Screening
This is your medical history form, to be completed prior to your first training session. All information will be kept confidential. This information will be used for the evaluation of your health and readiness to begin our exercise program. The form is extensive, but please try to make it as accurate and complete as possible. Please take your time and complete it carefully and thoroughly. Your answers will help us design a comprehensive program that meets your individual needs. If you have questions or concerns, I will help you with those after this form is completed. I realize that some parts of the form will be unclear to you. Do your best to complete the form. Your questions will be thoroughly addressed afterwards. It might be helpful for you to keep a written list of questions or concerns as you complete the medical history form.
General Information
Family Physician and/or Primary Health Care Provider:*
Doctor/Other :*
Doctor's Contact Number*
Please enter a valid phone number.
Doctor's Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
May I send a copy of your consultation to your physician or primaryhealth care provider and consult with them as necessary?*
YesNo

Women only answer the following. Do you have:
Menstrual period problems?Significant childbirth - related problems?Urine loss when you cough, sneeze or laugh?Are you on any type of hormone replacement therapy?
Comments

Men and women answer the following:
List any prescription medications you are now taking:
List any self-prescribed medications, dietary supplements, or vita-mins you are now taking:
Date of last physical examination:
MonthDayYear
Date
Were the results normal/good?
Date of last chest X-ray:
MonthDayYear
Date
Were the results normal/good?
Date of last EKG or ECG:
MonthDayYear
Date
Were the results normal/good?
Date of last dental check up:
MonthDayYear
Date
Were the results normal/good?
List any other medical or diagnostic test you have had in the past two years:
List hospitalizations, including dates of and reasons for hospitalization:
List any drug allergies:

Family Medical History
Father's Current Age (If still alive):
My Father's current health is:
GoodPoor
Reason for poor health if selected:
If deceased, age at death:
Cause of death:
Mother's Current Age (If still alive):
My Mother's current health is:
GoodPoor
Reason for poor health if selected:
If deceased, age at death:
Cause of death:
Number of brothers if applicable
Number of sisters if applicable
Age range of siblings if applicable:
Any health problems among your siblings?

	Not at all	1 to2 times	3 to 4 times	Almost every day
Beef
Fish
Desserts
Pork
Fowl
Fried Foods

	Not at all	1 to2 times	3 to 4 times	Almost every day
Beer
Wine
Hard Liquor

Client Information

Occupation

General Statement of Program Objectives and Procedures:

Description of Potential Risks:

Description of Potential Benefits:

Your Measurements:

General Information

Present Medical History

Men and women answer the following:

Past Medical History

Family Medical History

Familial Diseases

Other Heart Disease Risk Factors