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Client Information Form
Nameyour full name
Address
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Gender
Phoneyour phone number
Birthdate
I'm interested in...check as many as are applicable
Emergency Contact
Nametheir full name
Relationshipto you
Phonetheir phone number
How did you hear about Sempose Fitness?
Please be as specific as possible...more details
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About You & Your History
Has your doctor ever said that you have a heart condition OR high blood pressure?
If you select "Yes" above, please provide more details here...
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Do you feel pain in your chest at rest, during your daily activities of living, OR while exercising?
If you select "Yes" above, please provide more details here...
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Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
If you select "Yes" above, please provide more details here...
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Are you currently taking prescribed medications for a chronic medical condition?
If you select "Yes" above, please provide more details here...
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Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?Please answer NO if you had a problem in the past, but it does NOT limit your current ability to be physically active.
If you select "Yes" above, please provide more details here...
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Has your doctor ever said that you should only do medically supervised physical activity?
If you answered NO to all of the questions above, you are cleared for physical activity. Please click "NEXT" and then skip to "STEP 5" to complete your form. If you answered YES to one or more of the questions above, COMPLETE STEPS 3 AND 4.
1. Do you have Arthritis, Osteoporosis, or Back Problems?If the above condition(s) is/are present, answer questions 1a-1c
1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?
1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?
2. Do you currently have Cancer of any kind?If the above condition(s) is/are present, answer questions 2a-2b.
2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?
2b. Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?
3. Do you have a Heart or Cardiovascular Condition?This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm
3a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?Answer NO if you are not currently taking medications or other treatments
3b. Do you have an irregular heart beat that requires medical management?(e.g., atrial fibrillation, premature ventricular contraction)
3c. Do you have chronic heart failure?
3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?
4. Do you have High Blood Pressure?If the above condition(s) is/are present, answer questions 4a-4b
4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?Answer NO if you are not currently taking medications or other treatments
4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?Answer YES if you do not know your resting blood pressure
5. Do you have any Metabolic Conditions?This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes
5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?
5b. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.
5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kindeys, OR the sensation in your toes and feet?
5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?
5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?
6. Do you have any Mental Health Problems or Learning Difficulties?This includes Alzheimer's, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome
6a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
6b. Do you have Down Syndrome AND back problems affecting nerves or muscles?
7. Do you have a Respiratory Disease?This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure
7a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?
7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/weeks), or have you used your rescue medication more than twice in the last week?
7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?
8. Do you have a Spinal Cord Injury?This includes Tetraplegia and Paraplegia
8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?Answer NO if you are not currently taking medications or other treatments
8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?
8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?
9. Have you had a Stroke?This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event
9a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?Answer NO if you are not currently taking medications or other treatments
9b. Do you have any impairment in walking or mobility?
9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?
10. Do you have any other medical condition not listed above or do you have two or more medical conditions?
10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?
10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?
10c. Do you currently live with two or more medical conditions?
Please list your medical condition(s) and any related medications here...Please list your medical condition(s) and any related medications here...
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How long has it been since you last exercised?
more details
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How well would you say you know your way around a weight room?
more details
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What does your typical day look like? (e.g., sitting all day, a lot of walking, biking to class, stairs vs elevators)
more details
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How many days per week are you willing to commit to exercise? (with or without a trainer)
more details
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Can you think of any specific skills you would like help improving?
more details
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What are your current health/fitness goals?
more details
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What do you expect from a personal trainer? (e.g., types of motivation, encouragement, friendly, tough, accountability)
more details
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On a scale from 1-10 (1 being terrible, 10 being excellent) how would you rate your eating habits?
Have you ever tracked what you eat?
Waiver, Release, & Assumption of Risk Form

This form is an important legal document. It explains the risks you are assuming by participation in an exercise program. It is important that you read and understand it completely. After you have done so, please type your name and sign in the spaces provided at the bottom.

Waiver, Informed Consent, and Covenant Not to Sue

I have volunteered to participate in a physical exercise regimen under the direction of Sempose Fitness LLC, which will include, but may not be limited to, weight and/or resistance training. In consideration of Sempose Fitness LLC’s agreement to instruct, assist, and train me, I do here and forever release and discharge and hereby hold harmless Sempose Fitness LLC, and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from. THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT THAT MAY MALFUNCTION OR BREAK (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT AND (3) OUR NEGLIGENT INSTRUCTION OR SUPERVISION.

Assumption of Risk

I realize that exercise might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. These changes include abnormal blood pressure; fainting; disorders in heartbeat; heart attack; and, in rare instances, death. I understand that as a result of my participation, I could suffer an injury or physical disorder that could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life. I recognize that an examination by my physician must be obtained prior to involvement in this exercise program. I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate. I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST Sempose Fitness LLC, or OTHERS REFERRED TO IN THIS DOCUMENT FOR ANY NEGLIGENCE OR THAT OF OUR EMPLOYEES, AGENTS, OR CONTRACTORS.

Photography and Audio/Video Recording

I hereby give Sempose Fitness LLC and Sempose Fitness LLC’s recording staff permission to video tape, photograph, and record my image and or likeness. I understand that such taping or recording may be used at the sole discretion of Sempose Fitness LLC. I also understand my giving permission is in no way an endorsement of Sempose Fitness LLC or any product(s) distributed by Sempose Fitness LLC.

Nameyour full name

By checking the following box and typing your name in the following space, you affirm that you have read and understand all of the information presented above.

I acknowledge that typing my name in the box below constitutes my legal signature and is binding as such.
Your E-Signature
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