New Client Forms - Personal Training

Personal Information

Personal Information

Client Readiness

PAR-Q

Exercise History

Please fill out this form as completely as possible. If you have any questions, DO NOT GUESS; ask your health coach for assistance.

Training Risks and Liability

Training Risks and Liability

Consent

Informed Consent

  • Personal Information
  • PAR-Q
  • Exercise History Questionnaire
  • Training Risks and Liability Agreement
  • Personal Training Consent Waiver

Basic Information

First Name

Last Name

Email

Phone Number (222-222-2222)

Birthdate (mm/dd/yyyy)

Gender

Address

Street

City

Zip Code

State

Emergency Contact Information

Full Name

Relationship

Phone Number (222-222-2222)

Physical Readiness

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

Do you feel pain in your chest when you perform physical activity?

In the past month, have you had chest pain when you were not performing any 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 any medication for your blood pressure or for a heart condition?

Do you know of any other reason why you should not engage in physical activity?

If you have answered YES to one or more of the above questions, consult your physician before engaging in physical activity. Tell your 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.

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can start becoming much more physically active. Begin slowly and build up gradually. This is the safest and easiest way to go.

DELAY BECOMING MUCH MORE ACTIVE IF: -You are not feeling well because of a temporary illness such as a cold or fever. Wait until you feel better. OR -If you are or may be pregnant. Talk to your doctor before you start becoming more physically 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. This PAR-Q is valid for a maximum of 12 months or until health conditions change so as to answer YES to any of the above questions. "By completing this form, I have read, understood and completed this questionnaire to the best of my ability and any questions that I have answered were honest and to my full satisfaction."

General and Medical History

What is your current occupation?

Does your occupation require extended periods of sitting?

Does your occupation require repetitive movements?

If yes, please explain.

Does your occupation require you to wear shoes with a heel (e.g., dress shoes)?

Does your occupation cause you mental stress?

Do you partake in any recreational physical activities (golf, skiing, etc.)?

If yes, please explain.

Have you ever had any injuries or chronic pain?

If yes, please explain.

Have you ever had any surgeries?

If yes, please explain.

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 specify.

Were you a high school and/or college athlete?

If yes, please specify.

Do you have any negative feelings toward, or have you had any bad experience with, physical-activity programs?

If yes, please explain.

Do you have any negative feelings toward, or have you had any bad experience with, fitness testing and evaluation?

If yes, please explain.

Rate yourself on a scale of 1 to 5 (1 indicating the lowest value and 5 the highest).

Characterize your present athletic ability.

When you exercise, how important is competition?

Characterize your present cardiovascular capacity.

Characterize your present muscular capacity.

Characterize your present flexibility capacity.

Exercise Program History

Do you start exercise programs but then find yourself unable to stick with them?

How many days per week are you willing to devote to an exercise program?

Are you currently involved in regular endurance (cardiovascular) exercise?

If yes, please specify the type of exercise.

Rate your perception of the exertion of your exercise program

Have you been exercising regularly?

For how many weeks/months/years have you been exercising regularly?

Activity Readiness

Can you exercise during your work day?

Would an exercise program benefit your job?

What types of exercise interest you?

If yes, please specify the type of exercise.

By how much would you like to change your current weight (if at all)?

Rank your goals in undertaking exercise: What do you want exercise to do for you?

Improve cardiovascular fitness

Facilitate body-fat weight loss

Reshape or tone my body

Improve performance for a specific sport

Improve moods and ability to cope with stress

Improve flexibility

Increase strength

Increase energy level

Increase overall health and well-being

Have you had or do you presently have any of the following?

Select all that apply.

Family History

Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions?

Please explain any of the boxes that you checked.

Activity History

How were you referred to LiveVivacity? (Please be specific.)

Why are you enrolling in this program? (Please be specific.)

Have you ever worked with a personal trainer before?

Date of your last physical examination performed by a physician:

Have you ever performed resistance training exercises in the past?

Do you smoke?

If you smoke, how much do you smoke per week?

What is your current body weight (not required)?

What was your body weight one year ago (not required)?

How tall are you?

11. Do you follow or have you recently followed any specific dietary intake plan and, in general, how do you feel about your nutritional habits?

List the medications you are presently taking.

List your personal health and fitness objectives.

INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM

1. PURPOSE AND EXPLANATION OF PROCEDURE
I hereby consent to voluntarily engage in an acceptable plan of personal fitness training. I also give consent to be placed in personal fitness training program activities which are recommended to me for improvement of dietary counseling, stress management, and health/fitness education activities. The levels of exercise I perform will be based upon my cardiorespiratory (heart and lungs) and muscular fitness. I understand that I may be required to undergo a graded exercise test prior to the start of my personal fitness training program in order to evaluate and assess my present level of fitness.

I will be given exact personal instructions regarding the amount and kind of exercise I should do. A professionally trained personal fitness trainer will provide leadership to direct my activities, monitor my performance, and otherwise evaluate my effort. Depending upon my health status, I may or may not be required to have my blood pressure and heart rate evaluated during these sessions to regulate my exercise within desired limits. I understand that I am expected to attend every session and to follow staff instructions with regard to exercise, stress management, and other health and fitness regarded programs. If I am taking prescribed medications, I have already so informed the program staff and further agree to so inform them promptly of any changes which my doctor or I have made with regard to use of these. I will be given the opportunity for periodic assessment and evaluation at regular intervals after the start of the program.

I have been informed that during my participation in the above described personal fitness training program, I will be asked to complete the physical activities unless symptoms such as fatigue, shortness of breath, chest discomfort or similar occurrences appear.

At this point, I have been advised that it is my complete right to decrease or stop exercise and that it is my obligation to inform the personal fitness training program personnel of my symptoms, should any develop.

I understand that during the performance of exercise, a personal fitness trainer will periodically monitor my performance and may also measure my pulse or blood pressure, or assess my feelings of effort for the purposes of monitoring my progress. I also understand that the personal fitness trainer may reduce or stop my exercise program when any of these findings so indicate that this should be done for my safety and benefit. I also understand that during the performance of my personal fitness training program, physical touching and positioning of my body may be necessary to assess my muscular and bodily reactions to specific exercises, as well as to ensure that I am using proper technique and body alignment. I expressly consent to the physical contact for the stated reasons above.

2. RISKS
It is my understanding and I have been informed that there exists the remote possibility during exercise of adverse changes including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare instances heart attack, stroke, or even death. I further understand and I have been informed that there exists the risk of bodily injury including, but not limited to, injuries to the muscles, ligaments, tendons, and joints of the body. I am aware that every effort will be made to minimize these occurrences by proper staff assessments of my condition before each personal fitness training session, staff supervision during exercise and by my own careful control of exercise efforts. I fully understand the risks associated with exercise, including the risk of bodily injury, heart attack, stroke or even death, but knowing these risks, it is my desire to participate as herein indicated.

3. BENEFITS TO BE EXPECTED AND ALTERNATIVES AVAILABLE TO EXERCISE
I understand that this program may or may not benefit my physical fitness or general health. I recognize that involvement in the personal fitness training sessions will allow me to learn proper ways to perform conditioning exercises, use fitness equipment and regulate physical effort. These experiences should benefit me by indicating how my physical limitations may affect my ability to perform various physical activities. I further understand that if I closely follow the program instructions, that I will likely improve my exercise capacity and fitness level after a period of 3-6 months.

4. CONFIDENTIALITY AND USE OF INFORMATION
I have been informed that the information which is obtained in this personal fitness training program will be treated as privileged and confidential and will consequently not be released or revealed to any person who is not a LiveVivacity trainer. I consent to the use of any information which is not personally identifiable with me for research and statistical purposes so long as same does not identify my person or provide facts which could lead to my identification. Any other information obtained, however, will be used only by the program staff to evaluate my exercise status or needs.

5. INQUIRIES AND FREEDOM OF CONSENT
I have been given an opportunity to ask questions as to the procedures.

Agreement

Liability Waiver

ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT DECLARATIONS:

This Agreement is entered into between LiveVivacity, LLC and the undersigned (“Client”). The provision of personal training services by LiveVivacity to Client, whether through online coaching or private training, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement.

ASSUMPTION OF RISK: You agree that if you engage in physical exercise or activity, including personal training and online coaching, or enter a premises or use any facility or equipment on the premises for any purpose, you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided to you by LiveVivacity or otherwise, including injuries or damages arising out of the negligence of LiveVivacity, whether active or passive, or any of LiveVivacity’s affiliates, employees, agents, representatives, successors, and assigns. Your assumption of risk includes, but is not limited to, your use of any exercise equipment (mechanical or otherwise), sports fields, courts, or other areas, locker rooms, sidewalks, parking lots, stairs, pools, whirlpools, saunas, steam rooms, lobby or other general areas of any facilities, or any equipment. You assume the risk of your participation in any activity, class, program, instruction, or event, including but not limited to weightlifting, walking, jogging, running, aerobic activities, aquatic activities, tennis, basketball, volleyball, racquetball, or any other sporting or recreational endeavor. You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury, illness, damage, or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence of Trainer or otherwise.

RELEASE: You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge LiveVivacity (and LiveVivacity’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of LiveVivacity, whether active or passive, or any of LiveVivacity’s affiliates, employees, agents, representatives, successors, and assigns. This waiver and release of liability includes, without limitation, injuries which may occur as a result of (a) your use of any exercise equipment or facilities which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including personal training, (d) negligent hiring or retention of employees, and/or (e) slipping or tripping and falling while on any portion of a premises or while traveling to or from personal training, including injuries resulting from LiveVivacity’s or anyone else’s negligent inspection or maintenance of the facility or premises.
INDEMNIFICATION: By execution of this agreement, you hereby agree to indemnify and hold harmless LiveVivacity from any loss, liability, damage, or cost LiveVivacity may incur due to the provision of personal training by Trainer to you.
ACKNOWLEDGEMENTS: You expressly agree that the foregoing release, waiver, assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by the law in the State of Colorado and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. You acknowledge that LiveVivacity offers a service to its clients encompassing the entire recreational and/or fitness spectrum. LiveVivacity is not in the business of selling weightlifting equipment, exercise equipment, or other such products to the client, and the use of such items is incidental to the service provided by LiveVivacity. You acknowledge and agree that LiveVivacity does not place such items into the stream of commerce. This release is not intended as an attempted release of claims of gross negligence or intentional acts.

You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk and indemnity agreement. You are aware and agree that by executing this waiver and release, you are giving up your right to bring legal action or assert a claim against LiveVivacity, its employees, or its affiliates for LiveVivacity’s negligence, or the negligence of its employees or affiliates, or any defective product used while receiving personal training or any similar service from LiveVivacity. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.

IF UNDER 18, a parent or guardian must sign and acknowledge all risks and hazards outlined in this waiver.

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