inSHAPE Health History and Client Information
Please take the time to fill out our health history and client information form. This form will give us a chance to get to know you better. After filling out this form we will contact you regarding your free over the phone consultation!
Date of Birth
Cholesterol (#/ low, normal, high)
Blood Pressure (#/ low, normal, high)
How did you hear about inSHAPE?
Emergency Contact Name and relationship to client
Emergency Contact Phone Number
Check all goals that apply to you
Upper Body Tone
Lower Body Tone
Performance in an upcoming event
Healthier Eating Habits
Please list any additional goals:
Please indicate any timeline that you'd like to establish for your inSHAPE program:
Medical History (please indicate if you suffer from the following):
Asthma or other respiratory illness
Chest pain, heart disease, heart murmur, or other CVD
Cramps or swelling in ankles and legs
Lightheadedness, fainting, dizziness, seizures, or epilepsy
If you checked any of the above, please provide details below:
Check if you have suffered from any of the following orthopedic or muscular pain conditions in the last six months:
If you checked any of the above, please explain
Please list any medications you are on:
Please list any illness, hospitalization, or surgical procedure and the year in which they occurred:
Is there any other condition that might limit your participation in this program?
Please describe your typical nutrition/eating habits (breakfast/lunch/dinner/snacks):
Describe how much your weight has varied over the last 10 years, if at all?
How willing are you to accept recommendations for change in dietary plan?
In your opinion, how physically fit are you right now?
Do you currently exercise regularly?
If not, how long since you last did?
What types of exercise do you typically perform?
How many days per week?
Duration of a typical session?
Intensity of the sessions?
Please indicate the services that you are interested in:
In Home Personal Training
Date you would like to begin:
Days of the week that you can meet:
Please check all that apply
Times of the day that you can meet:
Before work (6-8 AM)
After work (6-8 PM)
Late morning (8-Noon)
Weekend warrior: morning
Weekend warrior: afternoon
Please add any other information we may need to schedule your sessions.
Please tell us a little about your workout space at home. Size, equipment, kids and/or pets running around...the more detail we have, the more prepared we will be when we get you started.
Informed Consent and Waiver of Liability for Exercise
I understand that I am responsible for monitoring my own condition throughout the exercise program. Should any unusual symptoms occur, I will cease my participation and inform the instructor of the symptoms.
In signing this consent form, I affirm that I have read this form in its entirety and that I understand the nature of, and risks associated with the Boot Camp exercise program. I also affirm that my questions regarding the exercise program have been answered to my satisfaction.
Also, in consideration for being allowed to participate in the exercise program, I agree to assume the risk of such exercise, and further agree to hold inSHAPE, llc and its instructors from any and all claims, suits, losses, or related causes of action for damages including, but not limited to such claims that may result from my injury or death, accidental or otherwise, during or arising in any way from, the exercise program.
Please type your complete name in agreement of the above consent.
Do Not Fill This Out