New Client Consultation Form

Last, First *

Date of Birth *

Best contact phone number *

Your current weight

Emergency Name and Phone Number *

Do you feel pain when you do physical activity? *

Has your doctor ever said that you have a cardiac condition? If YES, please list. *

Do you often feel faint or have spells of severe dizziness? *

How did you hear about us?

Please list the date of your last physical AND a diagnosis, if any. *

How do you spend most of your time through the day?

How many times per week do you engage in moderate or strenuous exercise for at least 30 minutes?

List medications you are taking and the reason for which they were prescribed

Do you have bone or joint problems such as arthritis that might be aggravated with exercise?

List any surgical procedures you have undergone, if applicable

Other Medical

I receive physical therapy or chiropractic care

I have bone or joint problems such as arthritis that might be aggravated with exercise

I have diabetes

I am or may be pregnant

terms

BY SUBMITTING THIS FORM I AGREE TO THE FOLLOWING: Physical exercise can be strenuous and subject to risk of serious injury, we urges you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity. You agree that if you engage in any physical exercise or activity, or use any amenity on the premises or off premises including any sponsored event, you do so entirely at your own risk. Any recommendation for changes in diet including the use of food supplements, weight reduction and/or body building enhancement products are entirely your responsibility and you should consult a physician prior to undergoing any dietary or food supplement changes. You agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness, or death. We are also not responsible for any loss of your personal property. This waiver and release of liability includes, without limitation, all injuries which may occur, regardless of negligence, as a result of; (a) your use of all amenities and equipment in the facility and your participation in any activity, class, program, personal training or instruction, (b) the sudden and unforeseen malfunctioning of any equipment (c) our instruction, training, supervision, or dietary recommendations and (d) your slipping and/or falling while in the club, or on the club premises, including adjacent sidewalks and parking areas. You acknowledge that you have carefully read this "waiver and release" and fully understand that it is a release of liability. You expressly agree to release and discharge the health club, and all affiliates, employees, agents, representatives, successors, or assigns, from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the club for negligence, personal injury or property damage. Note: Should any part of this agreement is found by a court of law to be against public policy or in violation of any state statute or case precedence, then the remainder of this document will remain in full force.