Skip to content
Facebook page opens in new window
Twitter page opens in new window
Facebook page opens in new window
Pinterest page opens in new window
Epic Fitness
Arizona's On-Site Personal Fitness Trainers
Home
Training Programs
Workplace Wellness
Virtual Training
Resident Wellness
Sports Conditioning
In-home Training
Meet Our Team
About Us
About Epic FItness
Testimonials
Client Info
FAQs
Health History Form
Fitness Glossary
BMI Calculator
Blog
Contact
Search:
Home
Training Programs
Workplace Wellness
Virtual Training
Resident Wellness
Sports Conditioning
In-home Training
Meet Our Team
About Us
About Epic FItness
Testimonials
Client Info
FAQs
Health History Form
Fitness Glossary
BMI Calculator
Blog
Contact
Health History Form
First Name
*
Last Name
*
Date of Birth
*
MM slash DD slash YYYY
Address
*
Street Address
City
ZIP Code
Cell Phone
*
Home Phone
*
Occupation
Emergenct Contact Name
*
Emergency Contact Phone
*
Health Information
Are you under the care of a physician, chiropractor, or other health care professional for any reason?
Yes
No
If yes, list reason
Are you currently taking any medications?
*
Yes
No
Please list the name and reason for taking.
*
Has your doctor ever said your blood pressure was too high?
*
Yes
No
Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise?
*
Yes
No
If yes, please explain
*
Is there any reason not mentioned why you should not follow a regular exercise program?
*
Yes
No
If yes, please explain
*
Have you worked with a personal fitness trainer in the past?
*
Yes
No
If you have worked with a trainer in the past, what did you like about your training?
*
If you have worked with a trainer in the past, what did you dislike about your training?
*
Fitness Survey
Answer the following questions on a scale from 1-10. 1 being the worst and 10 being the best.
How would you rate your current level of physical fitness?
*
Poor
2
3
4
5
6
7
8
9
Great
How would you rate your current diet/nutritional intake?
*
Poor
2
3
4
5
6
7
8
9
Great
How would you rate your energy level?
*
Low
2
3
4
5
6
7
8
9
High
How would you rate our current quality of sleep?
*
Low
2
3
4
5
6
7
8
9
High
How would you rate your average daily stress level?
*
Low
2
3
4
5
6
7
8
9
High
What are your health and fitness related goals?
Please make any other comments you feel are pertinent to your exercise program.
Agreement and Acknowledgement
I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and the cardio respiratory system (dizziness, discomfort in breathing, heart attack). I hereby certify that I know of no medical problem that would increase my risk of illness and injury as a result of participation in a regular exercise problem and that I have been cleared for all variations of cardiovascular and resistance training by my physician. I understand this is a release of liability and I agree to release and discharge both the fitness trainer and Epic Fitness LLC from any and all claims or causes of action and agree to voluntarily give up or waive any right that I may otherwise have to bring legal action against the fitness trainer or Epic Fitness LLC for injury or property damage. If any portion of this release of liability shall be deemed by a Court of competant jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.
By placing your initials below and submitting you agree to the above statement and acknowledge that the information contained here is required to provide a safe and productive training environment and that all information submitted is in fact true.
Enter initials
*
Go to Top
