" Purpose: To help you achieve your Health, Fitness and Nutrition Goals!
" Provision: Meeting your daily Health, Fitness and Nutrition needs.
" Pardon: Releasing the past mistakes of your Dieting and Exercising.
" Protection: Avoiding and fleeing the bad foods, media quakes being thrown at you daily and being a truth seeker.
" Perspective: Staying humbled yet excited about the goals you have achieved. NO Egos here.
Hours of Operation:
Mon through Fri: 5:00am-8:30pm Saturday: 7:00am-3:00pm
INITIAL EXERCISE CONSULTATION
How did you hear about me?
What location and time are you signed up for?
How many days are you doing each week?
May I send a copy of your consultation to your primary physician?
What are your exercise goals?
What are your nutrition goals?
Why are you choosing to utilize a personal trainer?
Health History Questionaire
Please select Y or N to any of these past or present problems. If yes, please explain why.
Are you taking any type of vitamins?
Are you taking any type of medication?
Are you currently exercising?
Days per week:
Minutes per day:
Describe exercise or activity:
Your current fitness level?
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
2. Do you feel pain in your chest when you do physical activity?
3. In the past month, have you had chest pain when you were not doing physical activity?
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
7. Do you know of any other reason why you should not do physical activity?
voluntarily consent to engage in a biomechanical stride analysis, cardiovascular fitness test, exercise prescription program, flexibility test, muscular endurance test, muscular strength test, and a running program. I understand any of these exercises or tests may involve me exerting myself beyond my normal exercise routines.
understand that certain physical changes could occur to me during these exercises and tests. Such occurrences that could happen are abnormal blood pressure, back problems, cardiac arrest, fainting, heart failure, knee problems, a reaction to any current medications that are being taken by the client, and any shoulder problems.
Even though I will be observed by Tod Esquivel during testing and training, I understand that I am responsible for monitoring my own condition throughout the procedures, and should any unusual symptoms occur, I will cease participation and inform Tod Esquivel of any and all symptoms.
also understand that an emergency could happen. In the event an emergency occurs, I am financially responsible for any emergency services that might be deemed necessary.
agree to assume all risks of the exercises and fitness testing and hereby release and hold harmless Tod Esquivel from all health claims, suits, losses, or cause of action for damages, injury or death, including claims for negligence, arising out of or related to my participation in the fitness assessment.
agree to call 1 hour before the scheduled workout to cancel my personal training session with Tod Esquivel or I will lose that training session.
If a client is late, he/she will be trained for the remainder of his/her session only. If Tod Esquivel is late more then 10 minutes, that session will be given at no charge to my client.
If you, my client does not show up for an appointment you will be assessed a full session charge. If Tod Esquivel does not show up, I will add an extra session at no charge to you.
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.
To the best of my knowledge, the information I have provided is accurate. I will inform Tod Esquivel of any changes in my health status as it changes in the future.