1. About You
Today's Date: Email Address:
Name:
I prefer to be called: Male Female
Birthdate: Age: SS#:
Home Address:
Hm. # Pager/Other #
Wk. # (incl. Ext.) DL #
How long there? Occupation:

2. Fitness Goals & History
1. How many times a week do you participate in resistance training ?

 

 
2. How many times and for what duration do you perform structured cardiovascular activity?

 

 
3. Do you participate in any other structured sports or activities and how frequently?

 

 
4. What are your current weight & fitness goals?

 

 
Height:___________ Weight:___________

D.O.B.:____/____/_____      Age:_____________

 

2. Medical History
Do you have a personal Physician? Yes or No
Physician's Name:
Your current physical health is: Good or Fair or Poor
Are you currently under the care of a Physician? Yes or No
Please explain:
Are you taking any prescription drugs? Yes or No
Please list each one:
Do you smoke or use tobacco in any other form? Yes or No
For Women: Are you taking birth control pills? Yes or No
Are you pregnant? Yes or No Week #:
Are you nursing? Yes or No
Have you ever had any of the following diseases or medical problems?
  Y N Abnormal Bleeding   Y N Alcohol/Drug Abuse 
  Y N Anemia   Y N High Blood Pressure
  Y N Arthritis   Y N HIV or AIDS
  Y N Artificial Bones/Joints/Valves   Y N Hospitalized for any reason
  Y N Asthma   Y N Kidney Problems
  Y N Blood Transfusion   Y N Liver Disease
  Y N Cancer/Chemotherapy   Y N Low Blood Pressure
  Y N Calitis   Y N Muscular Strains or Tears
  Y N Congenital Heart Disease   Y N Pacemaker
  Y N Diabetes   Y N Psychiatric Problems
  Y N Difficulty Breathing   Y N Radiation Treatment
  Y N Emphysema   Y N Reduced Range of Motion in any Joints
  Y N Epilepsy   Y N Seizures
  Y N Fainting Spells   Y N Shingles
  Y N Frequent Headaches   Y N Sickle Cell Disease/Traits
  Y N Glaucoma   Y N Sinus Problems

 
  Y N Hay Fever   Y N Joint Sprains or Breaks
  Y N Heart Attack   Y N Thyroid Problems
  Y N Heart Murmur   Y N Tuberculosis/TB
  Y N Heart Surgery   Y N Ulcers
  Y N Hemophiliac   Y N Venereal Disease
Please list any serious medical conditions or skeletal / muscular injuries you have ever suffered or are currently suffering from and please explain the circumstances and current or past treatment:

 

 

 

 

 

 

 
 
Please list any materials that you are allergic to:

3. General policies, Liability Waiver & Acceptance of Terms

RELEASE OF LIABILITY STATEMENT (PLEASE READ)

Please Read ! Edge Yoga and Fitness are in no way responsible  for the safekeeping of your belongings while you attend class or are in session with a trainer. Both resistance training & classes at the studio maybe physically strenuous, participation in either training or class is with full knowledge that there is a risk of personal injury, property loss or death. By participating in either class or personal training in either Edge Yoga or Edge Health & Fitness @ 2440 Wilson Boulevard Suites 201 &202 you agree that neither you nor your heirs or legal representatives will sue or make any claims against the studio, members or agents for any personal injury, property damage or loss, or wrongful death, whether caused by negligence or otherwise.

Print Name:__________________________

Signature:____________________________      Date:_____________

In order to protect the time of our trainers & encourage consistency in training we enforce a minimum 12 hour cancellation policy. If any session is canceled by a client without at least 12 hours notice the trainer is left with the discretion of charging the client for the session. In order to enforce this policy & protect the time of our trainers we also require prepayment of training sessions in bulk packages ranging from 5 to as many as 24 sessions (varies depending on the trainer).

Initial:__________       Date:_____________
All prepaid training packages are also (a.) non refundable (b. ) non transferable & (c.) valid / redeemable up to 12 months form the date of purchase.

Initial:__________       Date:_____________
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I also agree to all terms set out in above, in part 3. General policies, Liability Waiver & Acceptance of Terms.

Print Name:__________________________________


Signature________________________________ Date____________________