Health & Exercise History 

Name *
Name
Address *
Address
Primary Phone *
Primary Phone
Birth Date *
Birth Date
Sex
Emergency Contact Phone Number *
Emergency Contact Phone Number
What day(s) are you available to exercise? *
(Example: 6AM, 4PM, After 3PM, Between 6AM and 2PM, Mornings, or Afternoons, etc.)
Health Information
Physician's Phone Number
Physician's Phone Number
Please mark all TRUE statements. I currently experience the following symptoms: *
*If you did mark any of these statements please be aware that we will need a medical release form from your doctor before you engage in or resume exercise. This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of these questions. It is your responsibility to update the Studio if there are changes to your medical condition.
Please mark all TRUE statements. I currently have or have had the following medical conditions: *
*If you did mark any of these statements please be aware that we will need a medical release form from your doctor before you engage in or resume exercise. This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of these questions. It is your responsibility to update the Studio if there are changes to your medical condition.
(Ex. Chronic/former smoker, previous surgery, currently pregnant, receiving physical therapy, or additional medications).
Nutrition
If you answer "No" to receiving nutrition counseling with the Studio, you are welcome to skip down to the next section, "Your Goals."
(Example: Vegan, Low Sodium, Atkins, Paleo, etc.)
(Example: Over eating, not eating often enough, eating too much junk food, unbalanced diet, etc.)
Your Goals
Please indicate your belief in the importance of the following reasons for you to begin an exercise program: *
Please indicate your belief in the importance of the following reasons for you to begin an exercise program:
Improve cardiovascular fitness
Reshape or tone my body
Improve moods and ability to cope with stressors
Increase strength
Feel better
Body-fat weight loss
Improve performance for a specific sport
Improve flexibility
Increase energy level
Enjoyment
Signature
Please read the following statement. Type your first and last name indicating you have understood, and completed this questionnaire to the best of your ability. *
Please read the following statement. Type your first and last name indicating you have understood, and completed this questionnaire to the best of your ability.
Fredericksburg Fitness assumes no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity. Remember should your health change so that you then answer YES to any of the questions regarding medical conditions or symptoms tell your fitness and health professional. Ask whether you should change your physical activity plan. This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the medical conditions or symptoms questions on this form. I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction.