Informed Consent Form for Physical Fitness Program

Client Data Form

Your Name *


Sex *


Age *


Date of Birth *


Start Date


Street Address 1 *


Street Address 2


City *


State *


Zip *

Important Phone Numbers and E-mail Address

Home

Work

Cell

Email *

Emergency Contact Name *

Emergency Contact Number *

Doctor’s Name

Doctor’s Number

Hospital of Choice *

Client Questionnaire

Are you a…. Runner?
Yes No

Were you at one time?
Yes No

Are you a…. Triathlete?
Yes No

Were you at one time?
Yes No

Are you a…. Swimmer?
Yes No

Were you at one time?
Yes No

Other sport or recreational activities?

Who referred you to BodyFitz?

or, How did you hear about us?

How far do you drive to get here?

Do you keep a regular schedule?
Yes No

Time you awaken:

Time you go to sleep:

Are you currently under a Doctor’s care?
Yes No

If yes, explain:

When was the last time you had a physical examination?

Have you ever had an exercise test?
Yes No Unsure

If yes, were the results:
Normal Abnormal

Do you smoke?
Yes No

Do you take any medications on a regular basis?
Yes No

If yes, please list medications and reasons for taking:

Have you recently been hospitalized?
Yes No

If yes please explain:

Are you pregnant?
Yes No

Do you drink alcohol more than three times/week?
Yes No

Is your stress level high?
Yes No

Are you moderately active on most days of the week?
Yes No

Are you currently working?
Yes No
If so, how many hours per week?

What is your occupation?

If you are a student… How many credit hours are you currently taking?

What are your goals as they pertain to health, wellness, and fitness?

What is your current activity level?

a.How many times per week do you exercise?

b.For how long?

c.What is the intensity?

d.What activities do you do?

Do you have any special limitations (i.e., joint injuries, recent surgeries, disease, etc.) that can be made worse by exercise? Please describe any special conditions in detail.

How much time per day and per week are you willing to devote to exercise?

What kinds of activities interest you most?

If you have attempted a regular exercise program before, what would you describe as your greatest roadblock to consistency? What do you find most frustrating about achieving wellness?

How do you currently feel about your body weight/image?

Why will you succeed this time in sticking to your plan?

Have you experienced any of the following symptoms in the past month?

Chest pains when physically inactive or when physically active?
Yes No

Shortness of breath climbing a flight of stairs?
Yes No

Dizziness when rising from bed or a chair or anytime throughout the day?
Yes No

A loss of consciousness?
Yes No

Have you had any surgeries within the past year?
Yes No

If so, please explain:

Do you have any of the following limiting physical conditions?

Muscular dystrophy?
Yes No

Nerve or sensory damage?
Yes No

Multiple sclerosis?
Yes No

Other

Do you suffer from any of the following limiting orthopedic conditions?

Arthritis
Yes No

Bursitis
Yes No

Broken Bones
Yes No

Stress Fractures
Yes No

Prosthesis (hip, knee replacement, etc,)
Yes No

Other

Do you have:

High blood pressure?
Yes No

Diabetes?
Yes No

Known heart disease?
Yes No

Rheumatic heart disease?
Yes No

A heart murmur?
Yes No

Chest pain with exertion?
Yes No

Irregular heart beat or palpitations?
Yes No

Lightheadedness or do you faint?
Yes No

Unusual shortness of breath?
Yes No

Cramping pains in legs or feet?
Yes No

Emphysema?
Yes No

Other metabolic disorders (thyroid, kidney, etc.)?
Yes No

Epilepsy?
Yes No

Asthma?
Yes No

Back pain: upper, middle, lower?
Yes No

Other Join pain (explain)?
Yes No

Muscle pain or an injury (explain)?
Yes No

Have your parents or siblings had:

A heart attack?
Yes No

A stroke?
Yes No

High blood pressure?
Yes No

High cholesterol?
Yes No

Diabetes?
Yes No

If you answered yes to any of the above questions, what is his/her relationship to you, and what was his/her age at time of diagnosis?

What our members say

Nelson Castillo
Nelson Castillo

I was looking for a gym with personal one-to-one service instead of a big box facility. I stumbled upon BodyFitz in Sandy Springs, and initially spoke with its owner, Dan FitzSimons. Both professional and knowledgeable, he took me on a tour through BodyFitz, and I have to say the gym was immaculate: top-notch equipment .. Read More

 John Doe
Allison Prenger

BodyFitz makes it easy to roll out of bed at 5 am! It's so much fun to come and workout with the trainers here. Whether you are looking to tone up your arms for a wedding, get your butt kicked back into gear, recovering from an injury, or looking to simply maintain your health- there is a trainer here that is perfect for you.. Read More