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REGULAR EXERCISE

SF PERSONAL TRAINER COLLECTIVE

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Health History Form

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Address*
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Health History

This form is used to assess your present health and fitness status and it is not used to diagnose any medical condition/s. Please answer all the questions completely and to the best of your ability. If you do not know the answer to a question leave it blank and we will go over it again in person. The more accurate your answers the more we can help!
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*
Do you feel pain in your chest when you perform physical activity?*
In the past month, have you had chest pain when you were not performing any physical activity?*
Do you lose your balance because of dizziness or do you ever lose consciousness?*
Do you have a bone or joint problem that could be made worse by a change in your physical activity?*
Do you have high blood pressure?*
Do you have high blood sugar?*
Do you have high cholesterol?*
Have you had a surgical procedure within the last 5 years?*
Problems with hearing?*
Problems with vision?*
Date of last physical?*
Injuries*
Check box associated with any injury, basic details and year.
Are you currently being treated for any injuries?*
Do you have any chronic or serious illnesses?*
Are you presently taking any medications?*
Do you have any allergies? (Include all medications)*
Are you currently pregnant, or have you been in the past year?*
Have any of your parents of siblings had heart disease before age 55?*
Do you currently smoke cigarettes?*
Have you ever been a smoker?*
Please enter a number greater than or equal to 1990.
Do you have regular and healthy bowel movements?*
Have you ever seen a nutritionist or dietician?*
Does your job require you to travel?*
Do you commute to work?*
Do you have children?*
How much time per day are you willing to engage in activity that reinforce your training goals?*
Is it more important for you to continually feel challenged or to feel structured during your workouts?*
When you need to reduce stress do you ideally enjoy activities that are exciting, adventurous and give you a chance to blow off steam or activities that are relaxing?*
Do you enjoy exercise more when it involves a routine that you can adhere to or one that offers variety?*
Do you enjoy exercise more when it involves a routine that you can adhere to or one that offers variety?*

Occupation / LIfestyle

Does your occupation require repetitive movements?*
Does occupation cause you anxiety or mental stress?*
Would you say that your work is sedentary, active or physically strenuous?*
What style of hobby do you enjoy?*
Do you regularly participate in recreational activities?*
Recreational activities frequency:*
Do you have an exercise space and/or exercise equipment at home? **

Consent and Release Form

I hereby expressly consent to my participation in personal and/or small group training at Regular Exercise LLC. I acknowledge that such participation will necessarily involve participation in exercises that may be physically demanding and will subject the participant to stress, anxiety and possible hazards. I understand that the activity involves inherent other risks of INJURY.

I voluntarily agree to expressly assume all such risks that may result from the activity or in any way related to my participation in the activity. In consideration of the right to participate in the activity, I hereby release from any legal liability Regular Exercise LLC, and its instructors and all individuals assisting with the activity for injury or death caused by or resulting from my participation in the activity or in any way connected with my participation in the activity, whether such injury or death was caused by the alleged negligence of Regular Exercise LLC, another participant, or any other person or cause.

This agreement will apply for each and every day I engage in the activity without requiring me to sign an additional form for each. I further agree to defend and indemnify Regular Exercise LLC for loss or damage, including any that result from claims or lawsuits for personal injury, death, or personal property damage, relating to the activity of the Regular Exercise LLC facilities or equipment.

I represent that I am in satisfactory physical condition to participate in the activity and I authorize any person connected with the activity at Regular Exercise LLC to administer first aid to me, as they deem necessary. I authorize medical and surgical care and transportation to a medical facility or hospital for treatment necessary for my well being, at my expense.

The undersigned, (individual, parent or guardian) acknowledges that she/he is signing this agreement on behalf of (themselves, or a minor) and that the individual or minor shall be bound by the terms of the agreement.

Agreement and Consent*
Type your full name as agreement and consent.

Parent/Legal Guardian Agreement and Consent for age under 18

Parent/Legal Guardian Agreement and Consent for age under 18*
Type your full name as agreement and consent.

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 1401 Clement St
San Francisco, CA 94118


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