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Health History
What are your health and fitness goals?
What are (or could be) the obstacles that keep you from attaining those goals?
Do you smoke?
Yes
No
If yes, how many per day?
Do you consume alcohol?
Yes
No
If yes, how many drinks per week?
Have you suffered from any orthopedic injuries in the past five years? (e.g. sprains, strains, fractures, etc.)
Yes
No
If yes, please explain what and when.
Have you ever been diagnosed with:
High blood pressure
Yes
No
Diabetes
Yes
No
If yes,
Type 1
Type 2
Abnormal heart rhythm
Yes
No
Abnormal EKG
Yes
No
Hypo-/Hyperglycemia
Yes
No
Are you currently taking any prescription or herbal medication?
Yes
No
If yes, please list:
Women: Are you currently pregnant?
Yes
No
If yes, how many months?
Are there any other conditions that you currently or have suffered from?
If you answered yes to any of the health history questions, please provide your treating physician's contact information.
Physician's name
Phone #
Fax #
At your coach’s request, is it OK to contact the above physician regarding your condition(s)?
Yes
No
Agreement
I, the Client, voluntarily participate in the exercise program designed by the above named health and fitness Consultant. Consultant Responsibilities 1. Education. The above-named consultant (Consultant) agrees to maintain current professional certification and attend continuing education courses. 2. Hourly Service Log. The Consultant agrees to maintain a log of hours of services rendered and program plan. This log will be provided for the Client, if requested. 3. 24-Hour Cancellation. The Consultant agrees to give the Client a minimum of 24 hours notice of any necessary schedule changes. If the Consultant fails to give the Client adequate notice of appointment rescheduling, the Consultant will compensate the Client with a credit of one makeup session. Client Responsibilities 1. Health History. The Client has and will provide the Consultant with an honest and accurate Health History Questionnaire. 2. Changes in Health. The Client will promptly inform the Consultant of any change in health and any new injuries. 3. Medical History. The Client will allow the Consultant to contact the Client’s personal physician(s) when necessary. The Consultant agrees to obtain permission from the Client prior to any contact with the Client’s physician(s). 4. 24-Hour Cancellation Policy. I, the Client, agree to give the Consultant a minimum of 24 hours notice of necessary rescheduling of an appointment. I understand that I am responsible for full payment of services, if I fail to give the minimum, 24-hour notice of cancellation. 5. Scheduling and Fees Agreement. The Client agrees to comply with the advanced scheduling and fees policy set forth below. Scheduling & Fees 1. Scheduling Policy. The Client understands that the Consultant schedules all appointments on a monthly basis. Therefore, the Client will notify the Consultant of any schedule changes as soon as possible. 2. Billing Process. I, the Client, understand that I will be pre-billed monthly by the Consultant for services to be rendered. Invoices will be delivered via e-mail and/or hard copy on the first of each month. If services commence mid-month, I will be billed no later than the date of the first service. I understand that payment is due upon my receipt of the Consultant’s invoice. 3. Refund Policy. The Client understands that all payments will not be refunded. 4. Termination Agreement. I, the Client, understand that I have 72 hours to terminate agreement to begin services with the Consultant. A refund minus any services already rendered will be returned to me, as long as termination notice is received before the end of the 72-hour grace period. We have read and understand the above agreement. We agree to the above terms and conditions, and agree to work together toward meeting both the Client’s and Consultant’s goals and objectives.
I agree
