Fitness Document

Missy's Fitness

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Fitness Center Informed Consent Form

I, (print name) , give my consent to participate in the physical fitness evaluation program conducted by Missy's Enterprises, LLC.

Benefits

Participation in a regular program of physical activity has been shown to produce positive changes in a number of organ systems. These changes include increased work capacity, improved cardiovascular efficiency, and increased muscular strength, flexibility, power and endurance.

Risks

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 (except those noted below) that would increase my risk of illness and injury as a result of participation in a regular exercise program.

Testing and Evalution Results

I understand that I will undergo initial testing to determine my current physical fitness status. The testing will consist of completing this health inventory, taking a step test or bicycle ergo meter test for cardiovascular fitness, and being tested for muscular fitness and body composition.

I further understand that such screening is intended to provide the Fitness Center with essential information used in the development of individual fitness programs. I understand that my individual results will be made available only to me. I also understand that the testing is not intended to replace any other medical test or the services of my physician. I will be provided a copy of all test results. I may share the results with whomever I please, including my personal physician. By signing this consent form I understand that I am personally responsible for my actions during my tenure at Generic Fitness, and that I waive the responsibility of this center if I should incur any injury as a result of my negligence.

Signed: _______________________________ Date: ___/___/____

Witness: _______________________________ Date: ___/___/____


HEALTH HISTORY QUESTIONNAIRE

Answer each question by printing the nessary information. Your answers will be kept confidential.

Name:		Date of Birth:
Address:
City, State, Zip:
Home Phone:		Work Phone:
Employer:		Occupation:

Physician:		Phone:
Address:
City, State, Zip:

In case of emergency, please notify:
Name:		Relationship:
City, State, Zip:
Phone:

1.	Are you under the care of a physician, chiropractor, or other health care professional for any
	reason? Yes No

	If yes, list reason:

2.	Are you taking any medication? Yes (if yes, complete the following) No
	Type	Dosage/Frequency	Reason for taking




3.	Please list any allergies:


EXERCISE

Please check the box that best describes your work and exercise habits:

Intense occupational and recreational exertion
Moderate occupational and recreational exertion
Sedentary work and intense recreational exertion
Sedentary work and moderate recreational exertion
Sedentary work and light recreational exertion
Complete lack of all exertion

To what degree do you perceive your environment as stressful?


Signature of Client: _______________________________________ Date: ___/___/____

Signature of Witness: _______________________________________ Date: ___/___/____


I am not aware of any disease or disorder that would complicate my participation in a testing or exercise
programs, other than the medical conditions I have checked below.
Age: Gender: Male Female
Note: In order to assist you in the development of a rewarding physical fitness program, we need to have
your honest and accurate responses.

1. Has your doctor ever said your blood pressure was too high? Yes No

2. Has your doctor ever told you that you have a bone or joint Yes No
problem that has been or could be made worse by exercise?

3. Are you over the age 65? Yes No

4. Are you unaccustomed to vigorous exercise? Yes No

5. Is there any reason not mentioned here why you should not Yes No
follow a regular exercise program?

If so, please explain.

6. Have you recently experienced any chest pain associated with Yes No
either exercise or stress?

If so, please explain.

7. Do you have a family history of any of the following conditions? Yes No
Heart Disease Heart Attack
Hypertension High Cholesterol
Gout Angina
Abnormal EKG Diabetes
Asthma Other heart condition

SMOKING

Please check the answer that best describes your habits:

Non-user or former user. Date quit
Cigar and/or pipe
15 or less cigarettes per day
16 to 25 cigarettes per day
26 to 35 cigarettes per day
More than 35 cigarettes per day


FAMILY HISTORY OF CARDIOVASCULAR DISEASE (CV)

Please check the boxes that best describe your personal family history
(blood relatives only)

No known history of heart disease in family
One relative over age 60 with CV Disease
Two relative over age 60 with CV Disease
One relative under age 60 with CV Disease
Two relative under age 60 with CV Disease
Three relative under age 60 with CV Disease

MUSCULOSKELETAL

Please describe any past or current musculoskeletal conditions you have incurred such as
muscle pulls, sprains, fractures, surgery, back pain or general discomfort:

Head/neck:
Upper back:
Shoulder/clavicle:
Arm/elbow:
Wrist/hand:
Lower back:
Hip/pelvis:
Thigh/knee:
Lower leg/ankle/foot :

NUTRITIONAL

Are you on any specific food / nutritional plan at this time? Yes No
If so, please list:

Do you take dietary supplements? Yes No
If so, please list:

Do you experience any frequent weight fluctuations? Yes No

Have you experienced a recent weight gain or loss? Yes No
If yes, list change: Over how long?

How many beverages do you consume per day that contains caffeine?