Document Sample
					                                       Xcel Martial Arts
                        50 Westerview Drive Westerville, OH 43081


Please answer all questions accurately and honestly to allow us to fully determine your
individual needs.

First Name:________________________ Last Name: ______________________________________

Address: _______________________________________ City: _______________ Zip: ___________

Phone: ________________________________________ Alt Phone: __________________________

Age: ______ Height: ______________ Weight: _______________ Ideal Weight: ____________

1. Have you been a member of a health club before? Yes No

2. Have you been exercising regularly for the past 6 months? Yes No

3. During your last program did your progress slow dramatically after the first few weeks?
    Yes No

4. Do you smoke? Yes        No

5. Do you drink occasionally? Yes No

6. How long did you keep your last health club membership while not using the facility?
   ____ Months ____Yrs

7. How often do you eat out? __________ Times per week.

8. How often do you buy new clothes in an attempt to improve your self-image and/or
   _____ Times per month.

9. Please list the habits you would like to change:
10. What events in your life are coming up that will motivate you to reach your goals?
11. After reaching your goals, how will your life be different?

12. Over the past 10 years how many times have you started and stopped a nutrition and
exercise regiment?
    1 – 5 6 – 10 11 – 15 16 – 20        Too many to count

13. What external factors have derailed your progress in the past?
    Time Money No facility         Procrastination    Lack of support

14. In your own opinion, why did you fail to “stick with it”?
    Discipline    Knowledge      Experience        Accountability   Lack of expertise
                                                 Xcel Martial Arts
                               50 Westerview Drive Westerville, OH 43081

15. I would like to:
    Lose weight      Gain weight              Feel better          Look better          Live healthier

16. On a scale of 1 – 10, how serious are you about achieving your goals?
    1 2 3 4 5 6 7 8 9                       10

17. Has a physician ever diagnosed you with a heart condition and indicated you should restrict
your physical activity? Yes No

18. Do you ever faint or get dizzy and lose your balance? Yes No

19. Do you have an injury or orthopedic condition (such as a back, hip, or knee problem) that may
worsen due to a change in your physical activity? Yes No If yes, explain

20. Do you have high blood pressure or a heart condition in which a physician is currently
prescribing a medication? Yes No

21. Do you have insulin dependent diabetes? Yes                       No

22. Is there anything else your trainer should be aware of?

MARTIAL ARTS, LLC. Member acknowledges that the Personal Training/Fitness Assessment hereunder includes
participation in strenuous physical activities, including but not limited to, cardio fitness, weight training, steppers, kicking
bags and various resistance exercises (the “Physical Activities”). Member acknowledges these Physical Activities involve
inherent risk of physical injuries or other damages, including, but not limited to, heart attacks, muscle strains, pulls or
tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries and other
illness, soreness, or injury however caused, occurring during or after the Members participation in the Physical Activities.
Member further acknowledges that such risks include but are not limited to, injuries cased by the negligence of an
instructor or other person, defective or improperly used equipment, over exertion of a Member, slip and fall by Member, or
an unknown health problem of Member. Member agrees to assume all risk and responsibility involved with participation in
the Physical Activities. Member affirms that Member is in good physical condition and does not suffer from any disability
that would prevent or limit participation in the Physical Activities. Member acknowledges that participation will be
physically and mentally challenging, and Member agrees that it is the responsibility of Member to seek competent medical
or other professional advice regarding any concerns involved with the ability of Member to take part in the Physical
Activities. By signing this Agreement, Member asserts that he or she is capable of participating in the physical activities.
Member agrees to assume all risk and responsibility for exceeding his or her own physical limits. Member, on behalf of
Member, his or her heirs, assigns the next of kin, agrees to fully release XCEL MARTIAL ARTS, LLC (as well as any of its
owners, related entities, employees or other authorized agents, including Independent Contractors) from any and all
liability, claims and/or litigation actions that Member may have for injuries, disability or death or other damages of any
kind, including but not limited to punitive damages, arising out of participation in the Physical Activities, including but not
limited to the Personal Training/Nutritional Program and the Physical Activities, even if caused by the negligence,
intentional acts or omissions and/or any other type of fault of XCEL MARTIAL ARTSS, LLC, it’s owners, employees or
other authorized agents including Independent Contractors.

Member Signature: X______________________________________ Date: _________________
                                              Xcel Martial Arts
                          50 Westerview Drive Westerville, OH 43081

                                       Medical Clearance Form

Dear Doctor:

Your patient _____________________________________________ wishes to take part in an exercise
program and/or fitness assessment. The exercise program may include progressive resistance training,
flexibility exercises, and a cardiovascular program; increasing in duration and intensity over time. The
fitness assessment may include a sub-maximal cardiovascular fitness test and measurements of body
composition, flexibility, and muscular strength and endurance.

After completing a readiness questionnaire and discussing their medical condition(s) we agreed to seek
your advice in setting limitations to their program. By completing this form, you are not assuming any
responsibility for our exercise and assessment program. Please identify any recommendations or
restrictions for your patient's fitness program below (Physician's Recommendations).

                                  Patient's Consent and Authorization

I consent to and authorize __________________________________________ to release to Xcel Martial
Arts, health information concerning my ability to participate in an exercise program and/or fitness
assessment. I understand this consent is revocable except to the extent action has already been taken.
Authorization is not valid beyond one year from date of signature. Further disclosure or release of my
health information is prohibited without specific written consent of person to whom it pertains.

Member’s signature ___________________________________________ Date ___________
                      Parent signature if minor

                                     Physician's Recommendations

           I am not aware of any contraindications toward participation in a fitness program.

           I believe the applicant can participate, but urge caution because:

           The applicant should not engage in the following activities:

           I recommend the applicant not participate in the above fitness program.

Physician’s signature _______________________________________________Date _______________

Physician’s name (print)____________________________________________ Phone ______________

Address _______________________________________City ________________Zip ______________

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