Lionheart Personal Training » New Client Form

Contact Information

Name*

Address*

Home Phone*

Cell Phone*

Email*

Emergency Contact Name*

Emergency Contact Phone Number*

Age*

Date of Birth*

General Health History

How would you rate your fitness level?*

Do you currently have any health issues?*

Yes
No

If yes, please explain:

Have you had any major surgery or been hospitalized in the last year?*

Yes
No

If yes, please explain:

Cardiovascular/Circulatory History

Does your family have a history of heart disease?*

Yes
No

If yes, please explain:

Have you ever been diagnosed with a heart condition?*

Yes
No

If yes, please explain:

Do you frequently suffer from chest pains?*

Yes
No

If yes, please explain:

Do you often feel faint or have dizzy spells?*

Yes
No

If yes, please explain:

Do you have a history of high blood pressure?*

Yes
No

Do you smoke?*

Yes
No

Pulmonary History

Do you suffer from a pulmonary disease such as asthma or emphysema that might be aggravated with exercise or become worse with exercise?*

Yes
No

If yes, please explain:

Medications

Are you currently taking any medications?*

Yes
No

If yes, please explain:

Musculoskeletal History

Do you have a bone or joint problem such as arthritis that becomes aggravated with or becomes worse with exercise?*

Yes
No

If yes, please explain:

Are you currently receiving physical therapy or chiropractic treatment?*

Yes
No

If yes, please explain:

Do you have any concerns that have not been addressed in this questionnaire that you would like to mention before participating in a fitness program?*

Yes
No

If yes, please explain or speak directly with your trainer:

Informed Consent

I hereby agree to pay the below stated contract amount. Under the monthly training plan, the contract fees will renew every thirty (30) days from the start date of this program until canceled. I understand that I am purchasing sessions at a predetermined price. If there are extenuating circumstances that cause you to miss numerous sessions, please contact Lionheart at (314) 452-2392 to discuss a remedy. Clients canceling any appointments within 24 hours of a session will be charged the full price of the session. Clients using credit or debit card will be automatically deducted from a credit/debit account on or about their contract renewal date. Those choosing to pay with cash or check will be responsible for bringing their payment by their contact date. Failure to pay by contract date may result in a cancellation of services and/or late payment fees. The client is responsible for all late and collection fees. The intent to end services with Lionheart must be made at least five (5) days prior to rollover contract date in writing.

Client Signature*

*by typing your name, you are stating this is your signature*

Yes
No

Date*

Contact Information

General Health History

Cardiovascular/Circulatory History

Pulmonary History

Medications

Musculoskeletal History

Informed Consent

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