Personal Training Health History Client Information and Release Form Name * First Name Last Name Birth Date: * MM DD YYYY Gender * Female Male Email * Phone (###) ### #### Instagram Name General Medical History & Information I agree to provide honest and accurate responses to the questions below. Please list any current health problems that you feel are limiting your ability to exercise the way you want to, due to lack of energy, range of motion and or endurance: * If you are currently dealing with a chronic illness like Fibromyalgia, Chronic Fatigue or another similar condition, were there any significantly stressful events you think might have triggered your illness? * What was your lifestyle like before your chronic illness? (i.e. Active, Stressful, etc.) * What is your lifestyle like now? * Are there situations where you always feel worse afterwards, like exercising, working, being in noisy or heavily polluted areas, after eating a high carb or high fat meal, etc.? * What time of day do you feel your worst? * How well do you sleep? * Do you have bone or joint problems that could be made worse by exercising? * Are you taking any medications? If yes please indicate the type of medication and your reason for taking it. * Please list any known food allergies or intolerances. * Has your doctor ever said your blood pressure was too high or too low? * Do you currently exercise regularly? * Are there any reasons not mentioned thus far why you should not follow a regular exercise program? If so, please explain. * Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain or general discomfort: Head & Neck Upper Back Shoulder / Clavicle Arm / Elbow Wrist / Hand Lower Back Hip / Pelvis Thigh / Knee Lower Leg / Ankle / Foot Have you recently experienced any chest pain associated with either exercise or stress? If so, please explain. Do you have a family history of any of the following conditions? Heart Disease Heart Attack Hypertension Abnormal EKG Asthma High Cholesterol Angina Diabetes Other Heart Conditions Do you have a family history of cardiovascular disease? If so, how many occurrences and at what approximate ages? * Are you a smoker? If so, what is your smoking frequency? * Are you on any specific food/nutritional plan at this time? * How many beverages do you consume per day that contain caffeine? * Do you experience frequent weight fluctuations? * Have you experienced a recent weight gain or loss? If so, please explain the details including when it started. * CLIENT PROFILE QUESTIONNAIRE CURRENT EXERCISE INFORMATION: Please explain your current exercise regimen including all strength training, cardiovascular training, or other sporting activities that you perform. If you are currently dealing with a chronic illness how describe your exercise routine before you got sick. * What type of exercise do you currently do the most? (i.e. cardio intervals, steady state cardio, weight training, yoga, pilates, barre, etc.) * Is there any particular type of exercise that always causes you more pain or fatigue after doing it? * How many days a week do you usually exercise? * How many minutes of exercise feels best for your body right now? * What types of exercises do you enjoy doing the most? * What are your goals? * (check all that apply) Body Fat Loss Muscle Gain Improve Current Health Increase Flexibility How active are you and/or what is your exercise lifestyle like? * (choose one that applies the best) Sedentary Moderate Exercise Competitive Exercise Bodybuilding Does your job require you to be... * (choose one that applies the best) Sedentary Somewhat Active Active Very Active Is it hard for you to gain weight? * YES NO Can you eat a lot and still not gain weight? * YES NO Do you gain or lose weight according to your fluctuations in activity and food consumption? * YES NO Is it hard for you to lose weight? * YES NO Do you gain weight if you're not careful about food intake? * YES NO Please list the foods, beveragess, supplements, etc. that you consume on an average day. * If you are currently dealing with a chronic illness what was your diet like before you got sick? * Do you know of any food intolerances you might have? If so are you avoiding these foods? * Please list the foods you prefer to eat: * Please list the foods you prefer NOT to eat: * Please list foods you must restrict due to medical or other reasons: * Have you been instructed to follow a meal plan in the past? If so what was the reason and who provided it? * What is your current body shape? * Choose the closest one that applies. Triangle Apple Pear Where do you usually gain weight first and lose it last? Choose the closest one that applies. Chest & Upper Back Abs and Low Back Hips and Thighs If you own a body fat caliper or have recently been measured what is you current body fat percentage? If you currently own a heart rate monitor watch what is your current average resting heart rate and current average HRV (heart rate variability)? If you have a chance before you start your program, please take a progress photo of yourself and save it. It will inspire and motivate you later on! YOUR CURRENT MEASUREMENTS: What is your current weight? * Right Arm Measurement * Left Arm Measurement * Chest Measurement * (measure without a bra) Waist Measurement * (measure at the smallest part) Hips Measurement * (measure at the largest part) Right Thigh Measurement * Left Thigh Measurement * CLIENT COMMITMENT STATEMENT: Are you committed to your plan even if initially you don’t see or feel a lot of results right away? * (Remember results can take up to 6 weeks) Are you committed to learning how to really listen to your body’s cues and avoid the temptation to power through activities that cause you more pain? * Are you committed to stick to the CLF workouts most of the time, avoiding the temptation to try other more intense routines when you start feeling better? * Are you committed to making the changes to follow the simple lifestyle and nutrition guidelines I provide you with? * (There is no particular diet given so even if you have a nutritionist it will work) Are you committed to keeping track of your activities and diet each day as well as trying to journal how you are feeling throughout the day for the duration of your training? * CLIENT RELEASE, COVENANT NOT TO SUE WAIVER: I understand that the personal training I receive is provided for the purpose of exercise instruction and guidance. I further understand that personal trainers are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, or provide nutritional planning, and that nothing said in the course of the session(s) given should be considered as such. I should see a physician, chiropractor, registered dietitian or other qualified medical specialist for any nutritional concerns, mental or physical ailment that I am aware of. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the personal trainer updated as to any changes in my medical profile, and understand that there shall not be liability on the personal trainer's part should I forget to do so. I understand that I have enrolled in the personalized health and fitness program offered through Suzanne Wickremasinghe, Cocolime Fitness, Nirahlee, Inc. and its personal trainers and affiliates. I recognize that the program may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities. I herby affirm that I do not suffer from any known disability or condition which would prevent or limit my participation in this exercise program. I acknowledge that my enrollment and subsequent participation is purely voluntary and in no way mandated by Suzanne Wickremasinghe, Cocolime Fitness, Nirahlee, Inc. and its personal trainers and affiliates. In consideration of my participation in this program, I hereby release Suzanne Wickremasinghe, Cocolime Fitness, Nirahlee, Inc. and its personal trainers and affiliates from any claims, demands, and causes of action as a result of my voluntary participation and enrollment of the provided personal training services and/or exercise classes. I fully understand that I may injure myself as a result of my enrollment and subsequent participation in this program and I hereby release Suzanne Wickremasinghe, Cocolime Fitness, Nirahlee, Inc. and its personal trainers and affiliates from any liability now or in the future for conditions that I may obtain. These conditions may include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat protstration, injuries to knees, injuries to back, injuries to foot, or any other illness or soreness that I may incur, including death. Personal Training involves an inherent risk of physical injury and the undersigned assumes all such risks. The undersigned hereby agrees that for the sole consideration of Suzanne Wickremasinghe, Cocolime Fitness, Nirahlee, Inc. and its personal trainers and affiliates, allowing the undersigned to participate in the Personal Training Program for which or in connection with which Suzanne Wickremasinghe, Cocolime Fitness, Nirahlee, Inc. and its personal trainers and affiliates have made available any online training, the undersigned does hereby release, covenant not to sue, and forever discharge Suzanne Wickremasinghe, Cocolime Fitness, Nirahlee, Inc. and its personal trainers and affiliates of any and fora all claims, demands, rights, and causes of action of whatever kind or nature including but not limited to negligence, unforeseen bodily and personal recreational programs and activities. The undersigned understands that this Release, Covenant Not to Sue, Waiver, and Assumption of Risk shall be effective from the date of signature until the effective termination of the personal training services by Suzanne Wickremasinghe, Cocolime Fitness, Nirahlee, Inc. and its personal trainers and affiliates. By signing this document, the undersigned hereby acknowledges that he/she has read the above carefully before signing, and agrees to comply with all the above. I agree to all the above terms and conditions. Signature * Your name typed in the form below is your digital signature of agreement. Date * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you!
