Strategy Session Packet

Hello new friend and welcome to Results Fitness! Please complete this packet so we can learn all about you, understand your goals and help you live healthy, happy and strong for life!

First Name *

Last Name *

Street Address *

City *

Zip Code *

Phone Number as follows: 1112223333 (do not use any spaces, periods, hyphens or dashes). *

Email Address *

Nick Name *

Day of Birth * +

Emergency Contact: First + Last Name *

Emergency Contact Phone Number *

Hobbies? Special Talents? *

How did you hear about Results Fitness? *

What made you decide it was time to contact Results Fitness? *

What are your health, fitness and / or nutrition goals (think about the results / goals you want to achieve by working together)? *

What's kept you from acheiving these goal(s)? *

How many hours each week are you willing to dedicate to your health and fitness? *

Which program(s) are you most excited to learn more about? *

1:1 Personal Training

Small Group Personal Training

Classes

Nutrition Coaching

Are you currently exercising? If so, describe your fitness routine. *

Physical Activity Questionnaire

IF YOU ANSWER YES TO ONE OR MORE QUESTIONS BELOW: Talk with your doctor BEFORE you start becoming physically active and about the questions you answered "yes".

DELAY BECOMING MUCH MORE ACTIVE: If you are not feeling well because of a temporary illness such as cold or a fever - wait until you feel better. If you are or may be pregnant - talk to your doctor before you start becoming more active.

**Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

Check all that apply.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest or irregular heart beat when you do physical activity?

Have you had chest pain or irregular heart beat when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.

Results Fitness assumes no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire, I understand I must consult my doctor first before starting any physical activity. *

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Print First Name *

Print Last Name *

Health & Medical History

Physical activity should not pose any problem or hazard to the majority of people. The following questions are designed to identify the small number of adults for whom physical activity might be inappropriate or those who should seek medical advice prior to initiating a fitness program or other change in their physical activity levels.

Do you have any pain, discomfort or known current or previous injuries in any of these areas? Please check all that apply:

Please explain the nature of your pain and/or injury including what / if any activities or conditions aggravate the pain and/or injury.

Are you currently, or have you in the past, ever seen a chiropractor or physical therapist for any condition? If yes, when and for what condition?

Are there any other health, medical or injury conditions your trainer should be aware of? If yes, please explain:

I certify that I understand the foregoing questions and my answers are true and complete. I also understand that if this information changes in any way in the future, it is my responsibility to notify my personal trainer, and that I assume the risk for any changes in my medical condition that might affect my ability to exercise.

Before beginning a new fitness program or other significant change in your physical activity levels, you are advised to consult with your physician or primary health care provider. Only a physician or qualified health care provider is able to diagnose and prescribe treatment for specific health conditions.

I acknowledge that I have read the foregoing statements and fully understand the content thereof, and that if I choose not to consult with my physician or primary health care provider, I do so at my own risk. *

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Print First Name *

Print Last Name *

Waiver, Release & Assumption of Risk Form

I have volunteered to participate in a fitness and/or nutrition consulting program provided to me by Results Fitness (“Trainer”), which may include, but may not be limited to, resistance training, aerobic or cardiovascular exercise and weight management or nutritional counseling and/or advice. In consideration of Trainer’s agreement to counsel, instruct and train me, I do here now and forever release and discharge and hereby hold harmless Trainer and his respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from.

THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT BELONGING TO TRAINER OR TO MYSELF THAT MAY MALFUNCTION OR BREAK; (2) AND/OR ANY SLIP, FALL, DROPPING OF EQUIPMENT.

I have been informed of, understand and am aware that any exercise program, whether or not requiring the use of exercise equipment, is a potentially hazardous activity. I also have been informed of, understand and am aware that any exercise and/or fitness activities involve a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity, or death.

I have been advised that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program or initiating a substantial change in the amount of regular physical activity performed.

I have chosen not to obtain a physician’s consent prior to beginning this fitness program with Trainer, I hereby agree that I am doing so solely at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all fitness related activities and/or exercises in which I participate.

I further warrant that the program is to be utilized within the State of Ohio, and will hold harmless Results Fitness against any and all claims for liability and/or damages arising from any and all violation(s) of Codes, Statutes, Licensing Procedures, Licensure Examinations and/or Registration Requirements of such state, which govern the practice of dietetics and/or weight management and/or nutritional counseling and/or advice.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST TRAINER OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS.

This form is an important legal document that explains the risks you are assuming by beginning an exercise and/or nutritional consulting program. It is critical that you have read and understand this document completely. If you do not understand any part of this document, it is your ultimate responsibility to ask for clarification prior to signing it. *

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Print First Name *

Print Last Name *

Date * +

For individuals under the age of 18:

Parent/legal guardian signature for individuals under the age of 18:

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Parent/legal guardian: Print Last Name

Date +