New Client Intake FormsPlease fill out both forms on this page. I will be notified via email and reach out with next steps, thank you kindly. Name * First Name Last Name Email * Date MM DD YYYY Age * Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when you perform physical activity? * Yes No In the past month, have you had chest pain when you were not performing any physical activity? * Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? * Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? * Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? Yes No Do you know of any other reason why you should not engage in physical activity? * Yes No If YES to to the previous question, please explain here. Medical Check If you have answered YES to one or more of the above questions, consult your physician before engaging in physical activity. Tell you physician which questions you answered YES to. After medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition I have NOT answered YES to one or more questions I will contact my doctor for clearance General and Medical History * What is your current occupation and/or daily responsibilities? Does your occupation and/or daily responsibilities require extended periods of sitting? * Yes No Does your occupation or daily responsibilities require repetitive movements? * (If YES, please explain.) Does your current or previous occupation require you to wear shoes with a heel (e.g., dress shoes)? * Yes No Does your occupation or daily responsibilities cause you mental stress? * Yes No Do you partake in any recreational physical activities (golf, walking, swimming etc.)? (If YES, please explain.) * Have you ever had any injuries or chronic pain? (If YES, please explain and include year of incident.) * Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? (If YES, please explain.) * Are you currently taking any medication? (If YES, please explain if you are comfortable doing so.) * Have you ever had a personal trainer and/or a regular workout routine? If so, what did you like or dislike about it? * Additional information (YOUR goals, interests, etc.) Thank you! I will be reviewing and assessing your intake and reaching out to schedule your initial assessment at my earliest convenience. Please never hesitate to reach out with any questions. Thank you, stay well! Terms…A necessary personal training agreement for Steller Fitness LLC. Name * First Name Last Name Email * Select * If (non-emergency) cancellation is needed, please provide 24 hour notice, otherwise full session rate will be charged. I understand Select * If your trainer is more than 20 minutes late, a complimentary session will be arranged at client’s convenience. I understand Option 2 Select * If you are unable to continue any scheduled fitness programs due to a medical condition, please provide written documentation from your physician. I understand Option 2 Select * Please understand that your trainer cannot diagnose and/or prescribe treatment for any form of injury, disease, or other medical or dietary issues. I understand Select * I understand that participating in athletic training activities under any circumstances involves an inherent risk of physical injury to individuals undertaking such an activity, and that there will be conditions over which I have limited control. By signing this agreement, it is my express intent to waive, release and extinguish for myself, and anyone claiming by or through me, all liability, whether foreseeable or not, for any injuries to myself or any property, whether caused by negligence or otherwise. Communication is key, thank you! I agree and understand Option 2 Thanks so much for your commitment to YOUR health, and allowing me to help motivate you toward sustainable results!
