Fitness Questionnaire Fitness Questionaire First Name * Last Name * Phone * Email * Have you been a member of a gym before? Yes No Are you currently working out? Yes No If you are working out, what are you currently doing? Are you interested in our 6 week challenge or Small GroupTraining? * Yes No Already Signed up Do you have any medical issues or injuries that will impact your ability to workout? Yes No If “yes” please provide a brief summary of injuries and/or medical issues Do you need an equipment orientation? * Yes No Anything you would like to learn about in our session together? What days do you plan on working out? * Monday Tuesday Wednesday Thursday Friday Saturday Sunday Times you plan on coming into the gym. Early AM Am Lunch time PM Do you have a plan with your workouts? Fitness Hurdles * Time management Nutrition Snacks/Junk food Drinking water Sleep Alcohol Regularly eat out Other fitness hurdle Fitness goals * Lose weight Improve flexibility Reduce stress Increase cardio Improve nutrition Reduce low back pain Feel better overall Meet new fitness friends Detailed fitness goal (optional) On a scale of 1 – 10, how would you rate your nutrition? 1 2 3 4 5 6 7 8 9 10 Any upcoming events that are motivating you to reach your goals? On a scale of 1 – 10, how serious are you about achieving your goals? 1 2 3 4 5 6 7 8 9 10 In the past has there been anything that has stopped you from reaching your fitness goals? * Time Money Procrastination Discipline Lack of motivation Lack of experience Plateau No results Boredom Release and Waiver of Liability * RELEASE AND WAIVER OF LIABILITY MEMBERS ACKNOWLEDGEMENT AND ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF ANYTIME FITNESS: Member acknowledges that the Personal Training/Fitness Assessment hereunder includes participation in strenuous physical activities, including but not limited to, aerobic dance, weight training, stationary bicycling, various aerobic conditioning machines and various nutritional programs offered by Anytime Fitness (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, heats 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 caused 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 the Member to seek competent medical or other professional advice, regarding any concerns involved with the ability of Member to take part in Anytime Fitness 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 not exceeding his or her own physical limits. Member, on behalf of Member his or her heirs, assigns and next of kin, agrees to fully release Anytime Fitness (as well as any of its owners, 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 Anytime Fitness Activities, including but not limited to the Personal Training/Nutritional Programs and the Physical Activities, even if caused by the negligence, gross negligence, intentional acts or omissions and/or any other type of fault of Anytime Fitness, its owners, employees or other authorized agents, including independent contractors. If you are human, leave this field blank. Submit