Health History - Monmouth County Personal Trainer

Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Email *

Home Phone

Birth Date *

Age *

Cell Phone *

Work Phone

Emergency Contact *

Phone *

Welcome to Mike Duffy's Personal Training. So that we may train you to the best of our ability, please take a few minutes to answer the questions listed below. Thank you.

1) Do you have any injuries, illnesses or health issues that we need to know about? *

Yes
No

Please explain:

2) Do you currently take any medication(s)? *

Yes
No

Please list and explain:

3) What have you eaten so far today and what did you eat last night? *

4) Have you exercised regularly during the past two months? *

Yes
No

Please explain:

5) What are your goals? *

(Ex.: Lose weight, tone, strengthen body, rehabilitate an injury, athletic conditioning)

6) Do you have your doctor's permission to exercise? *

Yes
No

7) What is your blood type? *

RElEASE WAIVER REQUEST TO PARTICIPATE FORM

I consent to voluntarily participate in Mike Duffy's Personal Training exercise and nutrition program. have an understanding of my target heart range and understand it is my responsibility to monitor my level of exertion and pace myself accordingly.

I hereby release Mike Duffy's Personal Training and its staff and representatives from any responsibility and liability for any injury or health consequence as a result of negligence on the part of Mike Duffy's Personal Training that may occur from participation in this personal training exercise and nutrition program.

On occasion clients' personal information (including name, hometown, image) are captured in photographs and videotapes made for display of training activities. Some of the identifiers are used in the Mike Duffy Personal Training Studios, local media, mailers, emails and on the Mike Duffy Personal Training website and social media sites for promotional purposes only.

Signature below indicates permission for Mike Duffy to publish and use information as described above.

I have read and understand the foregoing. Any questions, which may have occurred to me, have been answered to my satisfaction.

Signature of Participant (Parent if under age 18) *

Date *