Lifestyle Assessment & Exercise History

Your Name:*
Your Email:*
How often do you check email?
Your Street Address:*

Telephone:

Home:
Cell:(optional)
Work:(optional)
Age:

Height:

Feet:
Inches:

Date of Birth:

Month:
Day:
Year:
Current Weight:
Weight six months ago:
Weight one year ago:
Occupation:
Hours per week:
Does your occupation require much activity (i.e. walking, getting up and down, carrying things)?
What are your usual leisure activities?
What role does exercise play in your life?
What are your personal barriers to exercise (i.e. your reasons for not exercising)?
Do you take any supplements or medications? If so, which?
Do you have any injuries or pre-existing medical conditions we should be aware of? Recent surgery?
Do you drink coffee, smoke cigarettes, or have any major addictions?
What is your chief concern?

Exercise History

Were you a high school or college athlete?
Do you have any negative feelings towards, or have you had any bad experiences with physical activity programs?
If yes, please explain

Rate yourself on a scale of 1 to 5 (1 indicating the lowest and 5 the highest). Check the number that best applies.

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

How much time are you willing to devote to an exercise program?

minutes/day
days/week
Are you currently involved in regular endurance (cardiovascular) exercise?
If yes, please specify the type of exercise(s) include minutes per day and days per week?
Rate your perception of your exercise program (1=light, 2=fairly light, 3=somewhat hard 4=hard 5= very hard)

How long have you been exercising regularly?

Years:
Months:

What other exercise, sport, or recreational activities have you participated in?

Past 6 months:
Past 5 years:
Can you exercise during your work day?
Do you have a gym in your building?
Do you currently belong to a gym? If so, which one?
Gym Name:
What types of exercise interest you?
What do you want exercise to do for you?
What time of day do you prefer to train?
What days are you available to train?
Do you have a preference for the gender of your trainer?

By how much would you like to change your current weight?

lbs (+)
lbs (-)
Service Purchased:
Other, please list:

Client Acknowledgement and Assumption of Risk and Full Release from Liability for TotalBodyFit LLC:

Client acknowledges that these physical activities involves the inherent risk of physical injury or other damages including but not limited to heart attacks, muscle strains, pulls or tears, and any other illness or injury caused occurring during or after client’s participation in the therapy. Client further acknowledges that such risks include but are not limited to injuries caused by the negligence of the therapist or other person, defective or improperly used equipment, slip and fall by client, or an unknown health problem of the client. Client affirms that client is in good physical condition and does not suffer from any disability that would prevent or limit participation in the therapy. Client agrees that it is the responsibility of client to seek competent medical or other professional advice regarding any concerns or activities. By signing the agreement, client asserts that he or she is capable of participations in the physical activities.

Please initial here:

Notice: Client, on behalf of client, his or her heirs, assigns and next of kin agree to fully release TotalBodyFit LLC (as well as any of its owners, employees, or other authorized agents including independent contractors) from any and all liability, claims, and/or litigation actions that buyer may have for injuries, disability or death or other damages of any kind including but not limited to punitive damages arising out of participation in TotalBodyFit LLC services including but not limited to massage therapy even if caused by the negligence, gross negligence, intentional acts or omissions and/or any other type of fault of TotalBodyFit LLC, its owners, employees, or other authorized agents including independent contractors.

Enter full name here as your electronic signature and acceptance of above terms:

Signature:

Date Signed (required)

Month (xx):
Day (xx):
Year (20xx):

All bookings require 24 hours advance booking and credit card guarantee. A full price of the treatment will be charged to your credit card for appointments that are rescheduled or cancelled less than 24 hours.


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