Contact Balance Fitness & Health Manchester CT Personal Training

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Balance Fitness & Health Intake Form

Name*

D.O.B //*

Address*

City*

Zip*

Contact Number:*

E-Mail:*

Your Goals

What is your goal?*

Why is this important to you?*

How motivated are you to achieve this goal?*

Did you view yourself as a person capable of exerting self disipline?*

Pertaining to goals, are there any other details you would like to add?*

Medical/ Orthopendic Conerns

Are you currently taking any prescription medications I should be aware?*

Do you have orthopendic/ mascular concerns or diagnoses?*

Do you have any condition(s) that could worsen by participating in physical activity ?*

Fitness Evaluation

Are you currently exercising?*

How long have you been exercising/training?*

Do you suffer from back pain?(upper /middle /lower)*

Do you have any injuries od limitations?(knee, shoulder, etc)*

Is there anything physically that you cannot do, what you have always wished you could do?*

Please give details of any training for the past 12 weeks. (please be detailed) *

Nutrition Evaluation

Do you have any food sensitivities(allergies) you are aware of?*

What foods, if any cause bloating/distention?*

Do you have sugar or salt cravings?*

If you answered yes, what time of day do you have cravings *

How would you described your relationship with food?*

Can you provide details of current dietay habits.*

Are you currently taking any suppliments?(multi-vitamin, D3,....etc)*

How much water do you consume daily?*

How many caffeinated drinks to you consume on daily basis? (Coffee / Tea / energy drinks/ soda) *

Sleep Evaluation

Do you have trouble falling asleep?*

Do you strggle to wake up in the morning?*

Do you sleep less than 8 hours a night?*

Do you wake up once or more during the night? *

What time do you wake up if you do?*

Do you sleep in a room with any light or noise?*

Do you go to bed later than 11pm?*

Do you use medications(OTC or PX) for sleep?*

Do you often have a midday crash in energy? *

How would you rate your daily stress level on a scale 1-10(1 being minimal stress)? *

HOLD HARMLESS AGREMENT

I hereby affirm that I am entering the course of instruction in physical fitness and performance training. By enrolling in this course, I certify that I am cognizant of all inherent dangers of physical fitness. I understand and am aware that resistance, flexibility, and aerobic exercise, including the use of equipment, is potentially hazardous activity. In consideration of enrolling in personal training activity, I hereby assume all risks connected width such activity including possible injury or death.Concious of all risk including death I am participating in these activities voluntarily and assume all responsibility by my involvement.

I hereby waive, release, and discharge the instructor, program and agents from any and all claims or liabilities for injuries or damages to my persons due to my participations. I also hereby indemnify and hold harmless all the above releass from any and all liabilities incident to my involvement in these programs,even if arising from their negligence.

I have read this release of liability and assumption of risk agreement, fully understand its terms,understand that i have given up substantial rights by signing it, and sign it freely and voluntary without and inducement.

Commitment/ Cancellatitoin Agreement

If you must cancell your session, please cancel no less than -hours of yoour scheduled time.

Cancelled session less than 12-hours will be charged.

I, agree to participate in trainingX per week for the next weeks. In the event I am unable to make my scheduled time(s) I am required to schedule a make up session for that week or the following. Failing to reschedule will forfeit the session resulting in a charge.

Your scheduled session is time you have committed to yourself and Balanace Fitness & Health. Lets work together to rienforce your goal and Healthy Lifestyle. Your continued Commitment will give you the consistency needed to reach your goals.

We have received your message and will get back to you as soon as possible.