History and Evaluation Assessment How did you hear about us? ___________________________________ Name: __________________________________________ Date: _____________ Address: ____________________________________________________________ City, State, ZIP: _________________________________________________________ Home Phone: ____________________ Cell phone: _______________________ Age:_______ Date of Birth:________________ *E-Mail:______________________________________________________________ If under 18, please list parent’s name & email: ______________________________________________________________________ Please list the type of training session(s) you are interested in: i.e Sports Prep, One-on-one, Boot Camp, Small Group Training, other ______________________________________________________________________ Preferred training time(s) _________________________________________ Office Use Only: Follow up email sent Start Date Scheduled Photo Taken Release Signed Initial Supplements _____ Added to in-house email _____ _____ Added to Newsletter _____ _____ Referral Names _____ _____ Nutritional Overview Scheduled _____ _____ Added to Volo _____ Matrix Goal Guarantee: If you attend all sessions and comply completely with the nutritional recommendations provided, you will achieve your agreed-upon goal, of your next month of sessions are free. What are your goals for this program? 1°_____________________________________________________________________ 2°_____________________________________________________________________ Are there any immediate timelines associated with these goals such as tryouts, important functions, vacations, etc? ____________ If so, please explain: ____________________________________________________ Do you agree with the goals and timelines we have set today? ________________ Signature: _____________________________________________________________ Dietary Adjustments: If your goal is weight management, you will be asked to follow a specific diet plan, unless you have a verifiable medical condition which prevents you from doing this. Do you feel you will be able to comply with this routine? (Y/N) If not, please explain. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Signature: ______________________________________________________________ Do you currently smoke? _____ If so, how much? _________________________ Do you consume alcohol? ______ If so, how much and how frequently? _______________________________________________________________________ Do you have any injuries, conditions or movement limitations that would prevent you from performing any exercise or activity? ________________________________________________________________________ ________________________________________________________________________ Do you currently have, or have you ever been diagnosed with any of the following: Hypertension (>140/90) High Cholesterol Diabetes Dizzy Spells Shortness of Breath Chest Pain Family History of Coronary Disease Have you had a recent physical? ___________ If so, are you cleared for physical activity? ___________ Are you currently involved with any regular recreational activities (golf, clubs, leagues, etc)? _________ If so, please list: ________________________________________________________________________ ____________________________________________________________ How would you describe you current nutritional habits/challenges? ________________________________________________________________________ Please list any food allergies you are aware of: ________________________________________________________________________ Please list any food(s) you will NOT incorporate into your diet. If you do not list specific foods here, they may appear in your diet plan: Vegetables: ____________________________________________________________ Meats: ________________________________________________________________ Dairy: ________________________________________________________________ Other: ________________________________________________________________ Do you take an Omega 3 or other “good fat” supplement? _______ If so, please list: ________________________________________________________________________ Do you take a Multi-Vitamin? _______ If so, please list the brand and any other supplements you may be currently taking: ________________________________________________________________________ ________________________________________________________________________ (If possible, please bring the container with you to the next session.) How many hours of sleep do you get per night? _________ Is your sleep interrupted regularly for any reason? _________ If “yes”, please explain ________________________________________________ On a Scale of 1 through 10, with 10 being the HIGHEST level, how would you describe the stress level in your life? ___________________________ Do you have friends, co-workers or family members who might benefit from 2 free weeks here? Persons listed below will receive a gift certificate from you for our services. 1)______________________________________________________________________ 2)______________________________________________________________________ 3)______________________________________________________________________ 4)______________________________________________________________________ Measurements: Current Bodyweight Target Bodyweight Body Fat % Body Fat % Waist Waist Hip Hip Neck Neck Biceps Biceps Upper Leg Upper Leg Male – Optional Chest Optional Chest - Male Hip To Waist Ratio – __________ Client Notes: (Please list any information that would impact client progress. i. e. Supplements taken/last order date, new injuries, job changes, medical conditions not covered, etc.) Use reverse of this sheet if necessary. ________________________________________________________________________ I. Overhead Squat Initial Test: Movement Limitation (Circle): Yes No Muscle group Limitation(s):______________________________________________ Follow up #1 Yes No Muscle group limitation(s):____________________________________________________________ II. Klatt test Initial Test Follow up Max Height dropped: _________ _________ Vastus medialis: ________ L_______R ________L ________R Hamstrings: ________ L_______R ________L ________R Hip rotators: ________ L_______R ________L ________R Q-L (General Torso): ________ L_______R ________L ________R Glutes: ________ L_______R ________L ________R Adductors ________ L_______ R ________L ________R Low Back ________ L_______ R ________L ________R III. McGill Torso Endurance Test: Initial Follow up Left Lateral Side Bridge _______ _______ Right Lateral Side Bridge _______ _______ Ratios: 1) Right side : Left Side Indication of Imbalance > or - > .05 _______ IV. Vertical Jump _____________ V. Chin Ups (Palms facing) ___________ VI. VO2 Max – Circle one version depending upon facilities available Beep Test: Level: ______ Cones: ______ Treadmill V02 Max Projected VO2 Max: ________ Time:_________ VII. Flexibility – Indicate Pass or Fail (If “Fail”, indicate number of degrees short of ideal) Follow up Piriformis: L________ Target 0° R________ Actual_______ _______ Actual_______ _______ Medial Hamstrings: L________ Target > 90° Actual_______ _______ R________ Actual_______ _______ Sagittal Hamstring: L________ Target > 100°Actual_______ _______ R________ Actual_______ _______ Rectus Femoris: L________ Target > 90° Actual_______ _______ R________ Actual_______ _______ Quadriceps: L________ Target 120° Actual_______ _______ R________ Actual_______ _______ TFL (+ or -): L________ R________ Psoas: L________ Target -5° R________ _______ _______ Actual_______ _______ Actual_______ _______ Recommended Lifting Movements: _______________________________________ ________________________________________________________________________ ________________________________________________________________________ Recommended Pre-workout Activities: _________________________________ ________________________________________________________________________ ________________________________________________________________________ Recommended Post-workout Flexibility: __________________________________ ________________________________________________________________________ ________________________________________________________________________ Matrix Strength & Fitness, Inc . AGREEMENT RELEASE FROM LIABILITY 1) I, ______________________, for good and proper consideration, do hereby freely and voluntarily acknowledge and appreciate the services and activities I wish to engage in with Matrix Strength & Fitness, Inc., their employees, servants, agents and assigns, such as weight training, flexibility and aerobic exercises to include the use of the various equipment are inherently risky and potentially dangerous activities. I freely and voluntarily choose to engage in these potentially dangerous activities and assume and accept any and all risk, including serious injury or even death. (Please initial________). 2) I do hereby forever waive, release, absolve, discharge and hold blameless Matrix Strength & Fitness, Inc., their employees, servants, agents and assigns, from any and all liability, loss, injury, damage, costs, claims and/or causes of action, including those caused by the negligent acts or omissions, including but not limited to the use of equipment at any site including my home, provided by and/or recommended by said persons or of those acting on their behalf, arising out of my participation in these dangerous activities. (Please initial______). 3) I do hereby further declare myself to be physically and mentally sound and suffering from no condition, disease, infirmity or other illness that would prevent or impair my participation or use of the equipment. I do hereby acknowledge that I have discussed my participation in these potentially dangerous activities with a physician and have been cleared to participate or that I have freely and voluntarily decided to participate in these potentially dangerous activities without the approval of a physician and do hereby assume all responsibility for my participation. I acknowledge that it is recommended that I have yearly or more frequent examinations and consultations with a physician regarding my participation in these activities, exercise and use of equipment. I further acknowledge and understand that Matrix Strength & Fitness, Inc.’s provision and maintenance of an exercise/fitness program for me does not constitute any acknowledgment, representation or indication of my physiological well-being or any medical opinion relating thereto. (Please initial_______). Understood and agreed to this ________day of ________________________, 20______. _____________________________ Client’s signature: ______________________________ Authorized representative