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Personal Training Intake Forms (2)
To save you time, please fill these necessary forms out. Print them out,
fill them out and bring them to your first appointment.
PHYSICAL ACTIVITY READINESS
QUESTIONNAIRE FORM 1
Name_______________________________________________________ Date______________________
The questions on this page are intended for your safety. Please check
off yes answers:
1. Has your doctor ever said
you have heart trouble or any cardiovascular problems? ______
2. Do you frequently suffer from tightness or pain in your chest or down
your arm? ______
3. Have you ever suffered from a heart attack? ______
4. Do you ever experience an irregular or racing heart during exercise
or at rest? ______
5. Do you often feel faint or have spells of severe dizziness? ______
6. Has a doctor ever said that your blood pressure is too high? ______
7. Do you often have difficulty breathing? ______
8. Are you pregnant? ______
9. Are you over age 65 and not accustomed to vigorous exercise? ______
10. Are you diabetic? ______
11. Is there a good physical reason, not mentioned here, for which you
should not ______
follow a program of physical activity, even if you wanted to?
If you answered YES to any
one or more questions, you MUST consult with a physician and provide written
approval to Touch Fitness before you begin your exercise program.
Signature____________________________________________________Date______________________
Emergency Contact:
Name______________________________________________________Relationship________________
Phone: Home________________
Cell____________________ Work________________
Email________________
Address_______________________________________________________________________________
City_______________________________________
State_________________ Zip code_____________________
5) Brian, I want to add a button
on every intake form page that says:
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EXERCISE HISTORY (Form 2)
Name__________________________________________________________________
Date____________________________________________
Address_________________________________________________________________
Email___________________________________________
Phone: Home______________________________________Work__________________________________Cell_____________________________
Referred by:_______________________________________Relationship____________________________Date
of Birth______________________
What are your fitness/health
goals?__________________________________________________________________________________________
How can Touch Fitness best
help you to achieve your current goals?________________________________________________________________
Have you ever had a trainer
before?__________If yes, what did you like/dislike about working with
a trainer?______________________________
________________________________________________________________________________________________________________________
Are you exercising currently?
Yes___________ No__________
If yes, number of days/week and minutes/day you currently participate
in: Please circle activities that interest you now.:
Strength Training:______________________________________
Walking Jogging Running Swimming Pilates
Aerobic/Cardiovascular:_________________________________
Cycling Dancing Aerobics Spinning Step Class
Flexibility:____________________________________________
Strength Training In-line Skating (Rollerblading)
Alignment: ___________________________________________
Speed Skating Racquet Sports Yoga Climbing
Stress Reduction/Massage Therapy:_______________________
Skiing Snowboarding Cross Country Skiing
Recreational Activities:_________________________________ Stretching Other________________________.
Please rate your activity level
from 1 to 3 (3 is most active) for each age range through your present
age:
15-20yrs______ 21-30yrs______
31-40yrs______ 41-50yrs______ 51-60______ 61-70______
Do you monitor your heart rate
when you exercise? Yes__________ No_________
What is your ideal body weight?_________________What
is your current weight?___________________How tall are you?___________________
Have you tried any diets? If yes, please list: _____________________________________________________________________________________
Have you been diagnosed with an eating disorder? If yes, please list:
____________________ Depression?_________________________________
If yes, are you currently being treated?________________________________________________________________________________________
Are you currently seeing a nutritionist? Yes__________ No_________
What vitamins, supplements and/or medications you are taking?__________________________________________________________________
Do you have problems sticking
to an exercise program? If yes, please explain.________________________________________________________
________________________________________________________________________________________________________________________
How can Touch Fitness help
you stick to an exercise program?_____________________________________________________________________
________________________________________________________________________________________________________________________
Do you have a partner, friend or spouse you can ask to workout with you
on an ongoing basis? If yes, who?_______________________________
How physically fit do you feel
right now? Check one: Great______ Moderate______ Poor______
Do you have any pain or discomfort right now?_________________________________________________________________________________
Have you had any surgeries, injuries or accidents?______________________________________________________________________________
Are you pregnant? Yes_______No______ If yes, number of months?______ __________________Other
children?___________________________
Have you been working out prior to being pregnant? Yes_______No______
If yes, number of months? ___________________________________Do you have
permission from your OB/Gyn to exercise while pregnant? Yes_______ No______
Permission to call? Yes_______ No_____
Name of physician, OB/Gyn...____________________________________________Phone
Number_______________________________________
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Massage Therapy
• Medical Massage/Deep Tissue
• Maternity & Post-Natal Massage
• Essential Oil Delicious Massage
• Swedish/Relaxation Massage
• Sports/Event Massage
• Table Stretch
• Shiatsu/Acupressure
• Chair Massage
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Massage Therapy Intake Forms (1)
To save you time, please fill this necessary form out and click on the
submit button.
Massage Intake Form
Name:_____________________________________________________ Date:__________________________
Address:______________________ Apt.:_________ City:_________ State:_________
Zip: ______________
Home Phone: ______________________ Work: _____________________________
Cell: ________________
Fax:_____________________
Email :______________________
Url:__________________________________
I prefer to have appointments confirmed at: _____ Home_____ Work_____Cell_____Email
Date of Birth: ______________________ Age: ____________
Children: yes____no_____ Names & Ages___________________________ (Optional)
Emergency Contact:______________________________ Relation:_______________Phone:
______________
Physician’s Name:________________________________ Phone:________________
Permission to call?_____
How did you hear about Touch Fitness?______________________
I prefer: _______Light _______Med. _______Deep _______Mixed Pressure
I prefer: ______Cold ______Heat
I prefer: __________Music
I prefer: _____Oil _____Cream _____Scented _____Unscented
What kinds of massage have you had?_______________________
Comments/Likes/Dislikes?__________________________________________________
________________________________________________________________________Do
you have any sensitivities or allergies to massage oils or creams? yes___
no ____
What is the primary reason for your visit?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please list any injuries, accidents, surgeries, or fractures. (Include
dates and treatments.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any past injuries, accidents, surgeries, or fractures. (Include
dates and treatments.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________
What is your occupation? ___________________________________________ ________________________________________________________________________
Please list the Physical activities associated with occupation: _____________________________________________________________________________________________________________________________________________
List any discomforts you may feel from your occupation.
______________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list activity and frequency of exercise or athletic involvement.
________________________________________________________________________________________________________________________________________________
List any discomforts or injuries you are experiencing from exercise or
athletics.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
Number per day of: cigarettes:______cups of coffee:______glasses of alcohol:
________other:_____________
Are you pregnant?___________ Number of months:________ Is this your first
pregnancy?_________________
Do you have any metal rods, pins, plates, pacemaker surgically implanted
in your body?_____________________________If so, where?_______________________
Please check off any current conditions and any previous conditions:
_____ Asthma _____ Herpes _____ Rheumatoid Arthritis
_____ Cancer _____ Hypertension _____ Scoliosis
_____ Colitis _____ Lipomas _____ Shingles (H. Zoster)
_____ Diabetes _____ Lyme Disease _____ Swelling in Joints
_____ Dizziness _____ Multiple Sclerosis _____ Tuberculosis
_____ Epilepsy _____ Osteoporosis/arthritis _____ Ulcers
_____ Heart Disease _____ Psoriasis/Excema _____ VaricoseVeins
Please list any medications,
supplements, vitamins, or herbs you are currently using.
________________________________________________________________________
SUBMIT
Waiver
All clients must fill this out.
In order to ensure your safety and the high quality of service we provide,
please take a few minutes to fill out these forms and send them back to
us.
Thank you.
Agreement and Release of Liability
I, ________________________________, residing at ___________________________________________,
do hereby waive, release, and forever discharge Touch Fitness and its
officers, agents, employees, representatives, executors, and all others
from any and all responsibilities or liability from injuries or damages
resulting from my participation in any programs of exercise and/or massage
therapy. Program and/or session(s) may consist of Exercise, Evaluation,
Massage Therapy and/or other related exercises and techniques. (Please
initial______)
I do also hereby release all
of those mentioned and any others acting upon their behalf from any responsibility
or liability for any injury or damage to myself, including those caused
by the negligent act or omission of any of those mentioned or others acting
on their behalf or in any way arising out of or connected with my participation
in any activities of Touch Fitness or the use of any equipment at 140
East 46th Street, Suite 6B, New York, NY 10017. (Please initial______)
Every effort will be made to
minimize any discomfort and prevent injury by preliminary examination
and by observations during situations which may arise. To my knowledge,
I do not have any limiting physical condition or disability which would
preclude a program of exercise and/or massage therapy. I do hereby further
declare myself to be physically sound and suffering from no condition,
impairment, disease, infirmity, or other illness that would prevent my
participation or use of equipment or machinery except as hereinafter stated.
(Please initial______)
All participants prior to involvement
in a fitness and/or massage program should obtain a physician’s
examination. If a participant chooses not to obtain a physician’s
permission, he/she must sign the following statement:
I do hereby acknowledge that
I have been informed of the need for a physician’s approval for
participation in a program of exercise and/or massage therapy. I accept
complete responsibility for my health and well-being in the voluntary
exercise and/or massage therapy, and related testing and understand that
no responsibility is assumed by Sherrin Bernstein, Touch Fitness or any
affiliated health facilities used during the program of exercise and/or
massage therapy. (Please initial______)
I understand and am aware that
strength, flexibility, and aerobic exercise, including the use of equipment,
is a potentially hazardous activity. I also understand that fitness activities
involve a risk of injury and even death, and that I am voluntarily participating
in these activities and using equipment and machinery with knowledge of
the dangers involved. I hereby agree to expressly assume and accept any
and all risks of injury or death. (Please initial______)
I have read and agree to all
the policies of Touch Fitness as well as the terms of this instrument
and understand that I am signing a complete release and bar to any claim
resulting from the programs, therapy and/or treatment herein described.
In witness whereof, I, the undersigned, execute this release on the date
set below.
Signature______________________________________________Date_____________
Witness_______________________________________________Date_____________
SUBMIT
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