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