BUILD A BETTER YOU
Name: Date (mm/dd/yy): Telephone:
Emergency Contact Name: Emergency Contact Phone:
Regular exercise is beneficial to your health in general. However, one must be careful about any associated injury risks. Please fill out the following form carefully so that your trainer may be properly planned in accordance with your risk profile. Please answer the following questions in Yes or No:
1. Do you have a heart condition in which you should undertake only the kind of physical activity recommend by a physician? ---YesNo
2. When undertaking in physical activity, do you feel pain in your chest? ---YesNo
3. Have you ever experienced chest pain in the past two months while not performing any physical activity? ---YesNo
4. Do you ever lose consciousness, balance or feel dizzy? ---YesNo
5. Do you have a joint or bone problem that may get worse during physical activity? ---YesNo
6. Is a doctor currently prescribing medication to you for high blood pressure or heart condition? ---YesNo
7. Are you pregnant? ---YesNo
8. Do you know of any reason that you should not increase your physical activity? ---YesNo
9. Are you a man over the age of 45 or a woman over the age 55? ---YesNo
If you answered YES to any of these questions, please consult and get medical authorization to undertake the training program from a qualified doctor.
Note: If there are any changes in your physical health while undergoing training, please alert your personal trainer and doctor and ask if there are any changes that should be made to your physical activity.
I have read, fully understand and completed the above questionnaire honestly to my knowledge. I have answered every question truthfully. I understand that I will be going through a strenuous physical training routine during which I can acquire injury. I am voluntarily participating in this training program and take full responsibility for any risk or injury that might result. I agree to waive any claim or right to sue Roc Fitness Training, trainers, employees or anybody else associated with the training program for injuries to myself as a result of my training activity.
(By entering your name, you agree to accept the terms of the above document with an electronic signature.)