Health/Medical Questionnaire
1. Personal Information
Name _________________________________________________________________________
Address _______________________________________________________________________
City________________________________________________________State_______________
Zip Code_______________________________ Phone __________________________________
E-mail_________________________________________________________________________
Past Injuries ____________________________________________________________________
Medical Restrictions _____________________________________________________________
Prescriptions/Medications_________________________________________________________
2. Medical History
Yes No
1. Do you have chest pain brought on by physical activity?
____ ____
2. Have you ever been diagnosed with High/Low Blood Pressure?
____ ____
3. Have you ever been diagnosed with Diabetes or any other medical condition?
____ ____
4. Have you ever been diagnosed with High Cholesterol?
____ ____
5. Are you aware, through your own experience or a doctor’s advice, of any other physical reason
against your exercising without medical supervision?
____ ____
6. Do you have any Joint or Skeletal issue? (Breaks, Dislocation, Fractures)
____ ____
7. Do you have a heart condition or have a family history of heart conditions?
____ ____
8. Are you currently on any medications? If so, please list.
____ ____
If you have answered YES to one or more of the questions above, please answer and initial the
following:
9. Have you consulted your physician regarding increasing your physical activity and/or performing a
fitness assessment? ____ ____
None of the following questions are for diagnostic or treatment purposes.
1. What is your level of Physical Activity?
Yes No
a.
Do your currently exercise? If yes, how many times per week/duration?
b.
If no, have you exercised in the past?
c.
Have you previously been a member of a Gym?
d.
Have you ever participated in a personal/small group training program?
2. If you currently exercise, what exercise activities does your workout include?
______________________________________________________________________________
______________________________________________________________________________
3. What are your short and long term goals for exercise, health, and fitness?
Short Term:___________________________________________________________
Long Term:___________________________________________________________
4. On a scale of 1-10 how serious are you about reaching your goals? ________________
Informed Consent / Assumption of Risk:
I, ________________________, am aware that there are significant risks involved in all aspects of
physical training. I understand that the reaction of the heart, lungs and vascular system to exercise
cannot always be predicted with accuracy. I understand that there is a risk of certain abnormal changes
occurring during or following exercise which may include abnormalities of blood pressure or heart rate;
chest, arm or leg discomfort; transient light-headedness or fainting; and in rare instances, heart attack,
stroke or even death. Excessive work can result (in rare cases) in exertional rhabdomyolosis. I should
look for signs of excessive soreness, darkened urine, and pain in the kidney areas in the days following a
particularly intense workout. While this type of injury is relatively rare, it can occur due to a number of
factors, including (but not limited to) genetic predisposition or dehydration, that may be beyond the
control of my trainer. I understand that the programs and classes offered by Evolution Barbell
Club/Training For Warriors – Doylestown/Plumsteadville Firehouse are of a nature and kind that are
extremely strenuous and can/may push me to the limits of my physical abilities. These risks include, but
are not limited to: falls which can result in serious injury or death, injury or death due to negligence on
the part of myself, my training partner, or other people around me, injury or death due to improper use
or failure of equipment. I am aware that any of these above mentioned risks may result in serious injury
or death to myself and or my partner(s).
X
I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my
participation in Evolution Barbell Club/Training For Warriors – Doylestown/Plumsteadville Firehouse
programs/classes and accept full responsibility for any injury or death that may result from participation
in any activity, class or physical fitness program. I hereby certify that I know of no medical problems that
would increase my risk of illness and injury as a result of participation in a fitness program designed by
Evolution Barbell Club/Training For Warriors – Doylestown/Plumsteadville Firehouse. With my full
understanding of the above information, I agree to assume any and all risk associated with my
participation in Evolution Barbell Club/Training For Warriors – Doylestown/Plumsteadville Firehouse.
X
By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of
progressive, physical exercise. By signing this document, I acknowledge being informed of the strenuous
nature of the program and the potential for unusual, but possible, physiological results including, but
not limited to, abnormal blood pressure, rhabdomyolosis, fainting, heart attack, or death. By signing this
document, I assume all risk for my health and well-being and hold Evolution Barbell Club/Training For
Warriors – Doylestown/Plumsteadville Firehouse, as well as its owners, employees, and other
authorized agents including independent contractors, harmless there from. I understand that questions
about exercise procedure and recommendations are encouraged and welcome.
X
Waiver and Release of Liability
WAIVER AND RELEASE OF LIABILITY Training for Warriors, LLC advises you and all clients to
obtain a physical examination from a physician before using any exercise equipment or
participating in any exercise program. All exercises, including the use of weights and use of all
machinery, equipment and apparatus designed for exercising shall be at the client’s sole risk.
Client understands that the agreement to use, or selection of exercise programs, methods and
types of equipment shall be member’s sole responsibility, and TFW and its affiliate companies,
its officers, owners, agents, and employees harmless from any and all claims that may be
brought against them by client, client’s guests, or on client’s behalf for any such injuries or
claims. IT IS THE INTENTION OF THE UNDERSIGNED BY THIS INSTRUMENT, TO EXEMPT
AND RELIEVE TRAINING FOR WARRIORS LLC AND ITS AFFILIATES FROM ALL LIABILITY
FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY
NEGLIGENCE. The undersigned acknowledges that he/she has read this Waiver and Release
of Liability and has signed this agreement by their own free will. I CERTIFY THAT ALL
INFORMATION STATED IS CURRENT AND VALID AND AGREE TO PARTICIPATE IN THE
TRAINING PROGRAM.
__________________________________________ _________________________
Client Signature
Date
Promotional Release
I hereby permit Training for Warriors, LLC to use my name, image and likeness for promotional
purposes limited to its training programs and facilities. Training for Warrior’s promotional
mediums include but are not limited to print, radio, video, television and the Internet.
I acknowledge that I have read this release and fully understood its contents. I am fully aware of
the legal consequences of signing this release. I voluntarily agree to the terms and conditions
stated above.
__________________________________________ _________________________
Client Signature
Date
Indemnification:
I recognize that there is risk involved in the types of activities offered by Evolution Barbell Club/Training
For Warriors – Doylestown/Plumsteadville Firehouse. Therefore I accept financial responsibility for any
injury that I may cause either to myself or to any other participant due to his/her negligence. Should the
above-mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and
costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to
indemnify and hold harmless Evolution Barbell Club/Training For Warriors – Doylestown/Plumsteadville
Firehouse, their principals, agents, employees, and volunteers from liability for the injury or death of any
person(s) and damage to property that may result from my negligent or intentional act or omission
while participating in activities offered by Evolution Barbell Club/Training For Warriors –
Doylestown/Plumsteadville Firehouse
I have fully read and fully understand the foregoing assumption of risk, and release of liability and I
understand that by signing it obligates me to indemnify the parties named for any liability for injury or
death of any person and damage to property caused by my negligent or intentional act or omission. I
understand that by signing this form I am waiving valuable legal rights.
I have carefully read this Agreement and fully understand its contents. I am aware that this is a release
and waiver of liability and sign it knowingly, voluntarily, and of my own free will.
X________________________
X________________________ __________________
Participant’s Signature
Participants name (printed)
Date
If the participant is under the age of 18,
X________________________
X________________________ __________________
Parent/guardian Signature
Parent/guardian name (printed) Date