Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Weight lbs

Height ft in

Occupation

Emergency Contact

First Name

Last Name

Physicians Name

First Name

Last Name

Physicians Phone Number

Budget

How much money have you set aside to work with a personal trainer, purchase food, and other programs to reach your goals?

What made you decide to do personal training?

What is your primary goal?

What are your favorite activities?

On a scale of 1-10, how would you rate your current fitness level (1=worst, 10=best)?

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

Health ~ PAR-Q Form Please mark YES or NO to the following:

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

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory aliments, back problems, etc)?

Are you pregnant now or have given birth within the last six months?

Have you had a recent surgery?

Do you take any medications, either prescription or non-prescription, on a regular basis?

What is the medication for?

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

If you marked yes to any of the above, please explain below:

Do you smoke?

If yes, how many per day?

Do you drink alcohol?

If yes, how many per day?

How many hours do you regularly sleep at night?

Does your job require you to travel?

On a scale from 1-10, how would you rate your stress level? (1=low, 10=high)

List your 3 biggest sources of stress

Do you regularly use the services of a massage therapist?

Do you regularly use the services of a Chiropractor?

Is anyone in your family overweight?

Were you overweight as a child?

How many hours do you work out per week?

If your participation is lower than you would like it to be, what are the reasons?

Lack of interest

Illness/Injury

Lack of Time

Lack of Knowledge

Other

Other:

Please explain

What activities are you presently involved in?

Cardio / Movement

Strength Training / Pilates

Stretching / Yoga

Sports and/or outdoor activities

Other

Other Activities

Which area would you like the most assistance with?

Realistically, how often would you like to exercise? __________ per week

Realistically, how much time would you like to spend during each exercise session? _______________

Based on your commitment, how often would you like to see a trainer to help you achieve your goals?

Other

What are the best days during the week for you to commit to your exercise program?

Sat

Sun

What are the best times for you to exercise?

Morning

Afternoon

Evening

If you could design your own exercise program, what would an ideal training week look like? Be specific.

What would you ultimately like to learn from a trainer/these sessions?

Other

In order to increase your chances of being successful at achieving your goals, ensure your goals are “SMART”

S=Specific (provide details, how much, how long, etc) M=Measurable (how will you measure when you’ve reached your goals) A=Attainable (be realistic, set smaller goals) R=Rewards-based (attach a reward to each goal) T=Time (set specific dates for goals) Please list in order of priority, the goals you would like to achieve in the next 3-12 months:

How important is it for you to achieve these goals?

How long have you been thinking about these goals?

How will you feel once you have achieved these goals?

Where do you rate health in your life?

Unhealthy

Average

Good

Where does your spouse/significant other/family rate health in their lives?

What do you think is the most important thing your trainer can do to help you achieve these goals?

List what you feel are the obstacles or potential actions, behaviors or activities that could impede your progress towards accomplishing your goals?

List three methods that you plan to use to overcome these obstacles

Nutrition On a scale from 1-5, how would you rate your nutrition (1=poor, 5=excellent)?

How many times throughout the day you eat?

Do you skip meals?

Do you eat breakfast?

Do you eat late at night?

What activities do you engage in while eating (TV, reading, etc)?

How many glasses of water do you consume daily?

Do you have decreased energy throughout the day or changes in mood?

What kinds of food do you regularly eat?

Do you know how many calories you consume in a day?

Have you every tracked your food intake (i.e. food diary)?

Are you currently taking a multi-vitamin or any other supplements?

How often do you eat out on a weekly basis?

Do you do your own cooking?

Do you do your own grocery shopping?

Besides hunger, what other reasons do you eat?

Bored

Social

Stressed

Tired

Depressed

Happy

Nervous

Do you eat mostly processed food or freshly prepared food?

Do you eat foods high in fat and sugar?

Do you eat past the point of fullness?

Do you prefer salty or sugary foods? S

Salty

Sugary

Both

Do you read nutrition labels?

If so, what do you look at?

List three areas that you would like to improve in the nutrition area:

Please list anything else that you may feel is a concern or information that has not been disclosed that may be pertinent to being physically active or working with a personal trainer.

Participant Release and Acknowledgement of Agreement

Participant Release and Acknowledgement of Agreement I, (Name Entered Above) wish to participate in the exercise and training program offered by Adam Rodman I understand there are inherent risks in participating in a program of strenuous exercise; consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. If I choose not to see a physician prior to beginning a fitness program, I do so strictly at my own risk. I also agree to provide Adam Rodman with my physician’s contact information so that Adam Rodman may receive direct clearance and program recommendations/limitations from my physician. I further agree that Adam Rodman shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, outdoors or in any fitness facility), and I expressly release and discharge Adam Rodman from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only and injury caused by an intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns. I have read and understand this term: __________ (Check Box Below)

Yes, I have read this

No, I have not

Liability Waiver

In consideration of my use of the exercise equipment and facilities provided by Stronger Version Fitness ("the company'), 1 expressly agree and contract, on behalf of myself, my heirs, executors, administrators, successors and assigns, that the company and its insurers, employees, officers, directors, and associates, shall not be liable for any damages arising from personal injuries (including death) sustained by me, or my guest in, on, or about the premises, or as a result of the use of the equipment or facilities, regardless of whether such injuries result, in whole or in part, from the negligence of the company. By the execution of this agreement, I accept and assume full responsibility for any and all injuries, damages (both economic and non-economic), and losses of any type, which may occur to me or my guest, and I hereby fully and forever release and discharge the company, its insurers, employees, officers, directors, and associates, from any and all claims, demands, damages, rights of action, or causes of action, present or future, whether the same be known or unknown, anticipated, or unanticipated, resulting from or arising out the use of said equipment and facilities. Texpressly agree to indemnify and hold the company harmless against any and all claims, demands, damages, rights of action, or causes of action, of any person or entity, that may arise from injuries or damages sustained by me or my guest. I agree to be solely responsible for safety and well being of my guest and myself. I understand that the company does not provide supervision, instruction, or assistance for the use of the facilities and equipment. I agree to comply with all rules imposed by the company regarding the use of the facilities and equipment. I agree to conduct myself in a controlled and reasonable manner at all times, and to refrain from using any equipment in a manner inconsistent with its intended design and purpose. I understand and acknowledge that the use of exercise equipment involves risk of serious injury, including permanent disability and death. I understand and agree that the company is not responsible for property that is lost, stolen, or damaged while in, on, or about the premises. I understand and agree that my use of the facilities and equipment is only to be undertaken on my own personal time, and that my use of the facilities and equipment is not within the course or scope of my employment. [ ] lintend that my minor child(ren), namely. is/are to be included in this Agreement of Release, Assumption of Risk and Waiver of Liability. I HAVE READ THE FOREGOING WAIVER AND RELEASE OF LIABILITY AND VOLUNTARILY EXECUTED THIS DOCUMENT WITH FULL KNOWLEDGE OF ITS CONTENT.

I consent

I do not consent

Understanding

I understand that Adam Rodman will make every reasonable effort to preserve the privacy of the information contained in this Client Intake Form. I further agree that Adam Rodman shall not be liable or responsible to me for any inadvertent disclosure of the information contained in the Client Intake Form and I expressly release and discharge Adam Rodman from all claims, actions, judgment and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any damage which may occur in connection with the disclosure of private information contained in the Client Intake Form. This release shall be binding upon my heirs, executors, administrators and assigns. I have read and understand this term:

Answers

I certify that the answers to the questions outlined on this form are true and complete to the best of my knowledge. I acknowledge that medical clearance is requested if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform Adam Rodman of any condition or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury. I have read and understand this term:

Obligation

I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform Adam Rodman. I have read and understand this term: __________ (initial) I understand that the results of any fitness program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions. I have read and understand this term:

Date

Mark the date as your virtual signature

YYYY

What is the best time to reach you?

Hour

Minute

Second

What is your prefered method of communication?

Phone Call

Text

Other

Thank you! I look forward to working with you.