Home
Services
Personal Training
>
30 Minute Private Sessions
Semi-Private Training
About Us
Photo Gallery
Testimonials
Tell us about you!
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
Date of Birth
*
Age
*
How did you hear about us?
*
Emergency Contact
*
First
Last
Emergency Contact Number
*
Do you have high cholesterol?
*
Yes
No
Has your doctor ever said that you have heart trouble?
*
Yes
No
Ever had a bone or joint problem (such as arthritis)?
*
Yes
No
Has your doctor ever said your blood pressure was too high?
*
Yes
No
Maybe
Do you or have you ever smoked?
*
Never
Quit tess than a year ago
Quit 1 - 3 years ago
Quit over a a decade ago
Smoking 1-3 years
Smoking over 3 years
Smoking over 10 years
If yes, how long?
Does anything prevent you from being physically active?
*
Yes
No
Please explain
Please Explain
*
Are you happy with the way you look and your health?
*
Yes
No
How serious are you about achieving your goals?
*
1 Not very serious
2 Undecided
3 Neutral
4 Semi-serious
5 Very Serious
Click all that apply
I am interested in:
*
Aerobics Classes
Free Weight Training
Cardiovascular Training
Circuit Training
Functional Training
I would like to:
*
Increase Muscle Tone
Lose Body Fat
Increase Stamina
Increase Strength/Lean Mass
Improve Overall Health
Have you been exercising?
*
Never
Not in the past year
1-6 months
1-3 years
Over 3 years
Over 10 years
Not for over a decade
Level of Activity (Choose One)
*
Sedentary --------------- little/no exercise
Lightly Active ----------- light exercise
Moderately Active ----- moderate exercise
Very Active -------------- hard exercise/sports 6-7 days/wk
Extra Active ------------- intense exercise/sport/physical job
Do you take Medications?
*
Yes
No
Please List All Medications
Please List All Medications, and their purpose, currently being used
*
Do you have problems with your:
Upper Back
*
Yes
No
Shoulders
*
Yes
No
Hips
*
Yes
No
Lower Back
*
Yes
No
Elbows
*
Yes
No
Knees
*
Yes
No
Neck
*
Yes
No
Wrists
*
Yes
No
Ankles
*
Yes
No
Are there any other medical conditions not listed on this form that you are or have been treated for that may prevent you from entering into a physical training program?
*
Yes
No
Client Consent
By initialling below, I acknowledge that I have voluntarily chosen to participate in a program of progressive physical exercise. I also acknowledge that I have been informed of the need to obtain a physician’s examination and approval prior to beginning this exercise program. In signing this document, I acknowledge being informed of the strenuous nature of the program and the potential unusual, but possible, physiological results including but not limited to abnormal blood pressure, fainting, muscle spasms, heart attack, soreness, or other ailments. I also understand that I may stop any training session at anytime. By signing this document, I assume all risk for my health and well-being and any responsibility, the instructor, facility or persons involved with the program and testing procedures.
Initial
*
Cancellation Policy
To help insure that you receive the most benefit from your training, Pure Muscle has instituted a strict Cancellation Policy.
Each client is allowed one (1) cancellation per 12-session period.
(If you have shared sessions, one of you may use the session to avoid losing said session.) To avoid being charged for a session,
please give 24-hour notice.
Each session cancelled or missed after the initial one (1), will be charged against your remaining sessions.
There is an automatic charge for any NO CALL/NO SHOW.
Temporary holds due to vacations, illness or other long-term obligations will not be deducted from your account when advanced notice is given. Also, please arrive early for your appointment. Time will be deducted from your session if you are late. Policy is subject to change at Pure Muscle’s discretion.
Initial
*
Include any additional comments you may like.
*
Submit
Home
Services
Personal Training
>
30 Minute Private Sessions
Semi-Private Training
About Us
Photo Gallery
Testimonials
Tell us about you!