Health & Fitness Questionnaire

Name *

First

Last

Home Address *

Phone Number *

Email *

Emergency Contact *

Emergency Contact Phone Number *

Gender *

Male
Female

Date Of Birth *

Height *

Weight *

Are you pregnant?

Do you have any medical health restrictions? *

If yes, please describe

Any bone, joint, recent surgery or other problems or limitations that must be addressed when developing an exercise program? *

If yes, please describe

Do you take any medications, either prescription or non-prescription on a regular basis that would affect your ability to exercise? *

If yes, please explain

Do you have your doctors approval to participate in a fitness / nutrition program? *

Have you ever worked with a personal trainer before? *

If yes, please describe your experience.

How would you rate your current fitness level? *

Poor
Good
Fair
Excellent

Have you been exercising regularly for the past 3 months *

No
2-4 days per week
1-2 days per week
5+ days per week

How many days per week can you commit towards exercise? *

1-2 days
4-5 days
2-3 days
5+ days

How much time can you commit to each exercise session? *

0-30 minutes
60-90 minutes
30-60 minutes
90+ minutes

Do you travel with your job? *

None
2-3 weeks per month
1 week per month
Every week

How would you rate your current nutrition level *

Poor
Good
Fair
Great

What is your nutrition goal? (Please check all that apply) *

Eat healthier
Gain weight
Lose weight
Maintain weight

How many times a day do you eat including snacks? *

1-2 times per day
4-5 times per day
3 times per day
More than 5 times per day

What type of eater are you (please check all that apply) *

On average how calories do you consume a day? *

Less than 1,000
1,500 to 2,000
1,000 to 1,500
2000+

How often do you eat out? *

1-2 meals per week
4-6 meals per week
2-4 meals per week
6+ meals per week

How much water do you drink per day? *

0 – 24 oz
48 – 64 oz
24 – 48 oz
64+ oz

Do you have any nutrition restrictions, allergies, religious, ethical or logistical limitations regarding your nutrition plan? *

If yes, please describe your nutrition restrictions.

Anything else you think we should know?

Your initial phone consultation will take approximately 1/2 hour, with that in mind, what is the best time to contact you *

7-11 am
1-5 pm
11 -1 pm
5-8pm

Waiver, informed consent, and covenant not to sue I have volunteered to receive an online training program from Jag Total Fitness, LLC – Denise Scott. The online personal training and nutrition counseling which will include, but may not be limited to, cardio, mobility (stretching), weight and/or resistance training, suggested meals, nutrition tips, and suggested supplements. In consideration of the Jag Total Fitness, LLC – Denise Scott online personal training agreement to provide said program, I do here and forever release and discharge and hereby hold harmless Jag Total Fitness, LLC – Denise Scott online personal training, and their 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 and nutrition program including any injuries resulting there from. This waiver and release of liability includes, without limitation, injuries which may occur as a result of my implementation of the program and/ or any negligent instruction or supervision. Assumption of risk – I recognize that exercise might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. These changes include abnormal blood pressure; fainting; disorders in heartbeat; heart attack; and, in rare instances, death. I also understand that any nutrition suggestions, tips, and written documentation are provided as a suggestion only and are not intended to treat any underlying medical or dietary conditions or replace the recommendations or treatment plan of your physician, dietary nutritionists or any other medical personnel. I understand that as a result of my participation, I could suffer an injury or physical disorder that could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life. I recognize that an examination by my physician must be obtained prior to involvement in this program. I acknowledge and agree that i assume the risks associated with any and all activities and/or exercises in which i participate. I understand that the information collected by Jag Total Fitness, LLC – Denise Scott online personal training will be used for fitness evaluation purposes and for the design, implementation, progression, and maintenance of an individualized fitness program only. I further understand that all personal and medical information is confidential and will not be shared with anyone without my prior authorization, except in the case of a medical emergency or to the minimum extent necessary to achieve a safe and effective fitness program. I further agree that the information i have provided in this health and fitness questionnaire is true and accurate. I acknowledge that I have thoroughly read this waiver and release and fully understand that itis 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 Jag Total Fitness, LLC – Denise Scott online personal training or others referred to in this document for any negligence or that of our employees, agents, or contractors. Please enter your full name in the text box below to agree and accept Jag Total Fitness, LLC policy and submit your Health and Fitness questionnaire. Sign If you agree to the above policy and validate that you are at least 18 years of age. *

By entering my full name below and clicking Confirm & Submit, I am electronically agreeing to and signing this document. *

First

Last