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New Client Intake Form
1. General Information
Name
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Phone Number
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Email Address
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Gender
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2. PAR-Q+ (Physical Activity Readiness) Questionnaire
Are you currently taking any medications?
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Have you had any surgeries within the last 5 years?
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Do you have any chronic illnesses or medical conditions?
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Have you ever been diagnosed with any heart conditions?
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Do you have diabetes or high blood pressure?
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Do you have any joint, bone, or mobility issues?
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Are you currently pregnant?
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Have you experienced any injuries in the past 12 months?
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Have you had any chest pain while exercising or at rest recently?
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Have you experienced dizziness or fainted in the past 12 months?
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Any other health complications that should be discussed?
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3. Liability Waiver & Release
Assumption of Risk
I understand that participation in fitness training, exercise programs, and related activities involves inherent risks including, but not limited to, muscle strains, sprains, abnormal blood pressure responses, heart-related events, falls, and other injuries.
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Assumption of RiskI understand that participation in fitness training, exercise programs, and related activities involves inherent risks including, but not limited to, muscle strains, sprains, abnormal blood pressure responses, heart-related events, falls, and other injuries.
I agree to and accept these risk
Release of Liability
I voluntarily agree to assume all risks associated with my participation and release, waive, and discharge the trainer, company, employees, contractors, and affiliates from any liability for injury, illness, death, or damages result.
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Release of LiabilityI voluntarily agree to assume all risks associated with my participation and release, waive, and discharge the trainer, company, employees, contractors, and affiliates from any liability for injury, illness, death, or damages result.
I agree to the release of liability
Emergency Medical Authorization
In the event of an emergency, I authorize emergency medical treatment as deemed necessary by qualified medical personnel.
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Emergency Medical AuthorizationIn the event of an emergency, I authorize emergency medical treatment as deemed necessary by qualified medical personnel.
I authorize emergency medical treatment if necessary
Patient Responsibility
I agree to provide accurate health information, inform my trainer of health changes, follow instructions and exercise safely, and to notify my trainer if I experience pain, dizziness, or any discomfort.
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Patient ResponsibilityI agree to provide accurate health information, inform my trainer of health changes, follow instructions and exercise safely, and to notify my trainer if I experience pain, dizziness, or any discomfort.
I agree to follow all instructions and participant responsibilities
Signature
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Signature
Submit
