Personal Profile Information Name: Birth Date: Address: City: State: Zip: E-mail: Weight: Male Phone: Height: Female   Emergency Contact Contact's Name: Relationship of Contact: Contact's Phone:   Lifestyle/Professional Activity How would you rate the activity level of your profession, or what you do during the day (non-exercise related). Sendentary Moderately Active Active Very Active   What Best Describes You? Sendentary Adult Exercising Adult Competitive Athlete Teenage Building Muscle Adult Building Muscle Athlete Restricting Calories   What are your training goals? (for example: gain muscle, gain strength, tone muscle, loss weight, learn fitness equipment)   What days and times are you available to meet with a trainer?   Do you prefer to work with a trainer of a specific gender? Male Female No Preference     What type of fitness equipment do you have at home? (for example: treadmill, Vectra home gym, free weights)   When do you want to begin your sessions?   Health & Medical Physician's Name: Physician's Phone: Has your physician approved your participation in an exercise program? Yes   No   Have you ever had? Chest pain, stroke, or heart problems? Yes No   High blood pressure or cholesterol? Yes No   Any chronic illness or condition (ex: diabetes)? Yes No   A physician tell you not to exercise? Yes No   Breathing or lung problems? Yes No   Bone or joint problems? Yes No   Back pain? Yes No   Hernia? Yes No     Please provide details to any YES answers to the above questions, or explain any other medical conditions:   Answer each of the following questions & explain below, as needed: Are you currently, or have you recently been, pregnant? Yes No   Have you had recent surgery? Yes No   Do you smoke? Yes No   Are you affected by any previous injuries? Yes No   Are you taking any medications or drugs for high blood pressure or a heart condition? Yes No     Please provide details to any YES answers to the above questions, or explain any other medical conditions:   Policies Personal training sessions must be canceled at least 12 hours before the scheduled session or you will be charged for the full training appointment. If you are dissatisfied with your original personal trainer we will schedule a new trainer to meet with you until your fitness needs are met. If you choose to discontinue your personal training session contract we will refund 80% of the remaining training sessions within 30 days. All training sessions must be used within a year from the date of purchase. Liability Waiver The following explains the risks you are assuming beginning a fitness and/or nutrition program. It is critical that you read and understand it completely. After you have done so, please print your name and date in the spaces below. Disclaimer The fitness and nutrition information given is meant only for the client / individual completing the forms. It is the sole responsibility of the client / individual to provide complete and accurate information. Any misrepresented information is solely the client's individual's responsibility and NuWeights Personal Training and Nutrition Services will not be liable. NuWeights Personal Training and Nutrition Services provides fitness and nutrition counseling only and is not licensed to diagnose a medical condition or illness. The client / individual must consult a physician for any medical advice. Waiver and Covenant Not to Sue I have volunteered to participate in a fitness and/or nutrition program under the direction of NuWeights. In consideration of NuWeights agreement to assist me, I do here and forever release and discharge and hereby hold harmless NuWeights Personal Training and Nutrition Services and its 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 any fitness or nutrition program including any injuries resulting there from. I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program. I understand that results are individual and may vary. Finished! Press the Submit button to forward your profile information to NuWeights. Yes   No Name:   Date:   Home | Our Team | Programs & Services | Insurance and Billing | Testimonials | Contact Us Getting Started | Brochures & Documents | Blog | Supplements & Vitamins | Shop Online Events & Media | Employment Opportunities | Medical Weight Loss | Traditional Weight Loss Bariatric Surgery Nutrition | Metabolism Testing | Nutrition Counseling | Personal Training
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