BAMmetrics Medical Release Form

Please fill out the medical release form below so Bobby can work with you at his next seminar or for training with him!

Step 1 of 6

16%

Today's Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Height

Weight

Age

Emergency Contact

Name

First Last

Relationship

Phone

Relationship

Physician's Name

Physician's Specialty

Phone

MEDICAL HISTORY

Are you currently under a physician's care?

Yes

When was the last time you had a physical examination?

Have you ever had an exercise stress test?

Yes

Not sure

Do you take any medications on a regular basis?

Yes

If yes, what were the results?

Normal

Abnormal

If yes, please list medications and reasons for taking:

Have you been recently hospitalized?

Yes

Do you smoke?

Yes

If yes, please explain:

Are you pregnant?

Yes

Do you drink alcohol more than 3x/week?

Yes

Is your stress level high?

Yes

Are you moderately active on most days of the week?

Yes

Do YOU have/have YOU had:

A heart attack?

Yes

A stroke?

Yes

High blood pressure?

Yes

High cholesterol?

Yes

Known heart disease?

Yes

Rheumatic heart disease?

Yes

A heart murmur?

Yes

Chest pain with exertion?

Yes

Irregular heart beat or palpitations?

Yes

Lightheadedness or history of fainting?

Yes

Unusual shortness of breath?

Yes

Cramping pains in legs or feet?

Yes

Emphysema?

Yes

Other metabolic disorders (thyroid, kidney, etc.)?

Yes

Epilepsy?

Yes

Asthma?

Yes

Back pain: upper, middle, lower?

Yes

Other joint pain?

Yes

Describe your back pain:

Describe your joint pain:

Muscle pain or an injury?

Yes

Describe your muscle pain or injury:

Do you have parents or siblings who, prior to age 55, have/had:

High blood pressure?

Yes

High cholesterol?

Yes

Diabetes?

Yes

HEALTH & FITNESS GOALS

How can a personal trainer help you? Please check all that apply.

Loose Body Fat

Develop Muscle Tone

Rehabilitate an Injury

Nutrition Education

Start an Exercise Program

Design a More Advanced Program

Safety

Sports Specific Training

Increase Muscle Size

Fun

Motivation

Other

List the fitness goals you would like to achieve in the next 3-12 months, in the order of priority.

How will you feel once you’ve achieved these goals? Be specific

Where do you rate the priority of health in your life?

Low

Medium

High

How committed are you to achieving your fitness goals?

Very

Semi

Not very

Current Swing Speed

Goal Swing Speed

Current Handicap

Goal Handicap

What do you think the most important thing your Personal Trainer can do to help you achieve your fitness goals?

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc.

Outline 3 methods that you plan to use to overcome these obstacle.

Improve mobility and performance, while reducing pain!

ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY

DECLARATIONS:
This Agreement is entered into between personal trainer Bobby Aldridge (“Trainer”) and the undersigned you (“Client”). The provision of personal training services by Trainer to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement.

ASSUMPTION OF RISK:
You agree that if you engage in any physical exercise or activity, including personal training, or enter our premises or use any facility or equipment on our premises for any purpose, you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided to you by Trainer or otherwise, including injuries or damages arising out of the negligence of Trainer, whether active or passive, or any of Trainer’s affiliates, employees, agents, representatives, successors, and assigns.

Your assumption of risk includes, but is not limited to, your use of any exercise equipment (mechanical or otherwise), sports fields, courts, or other areas, locker rooms, sidewalks, parking lots, stairs, pools, whirlpools, saunas, steam rooms, lobby or other general areas of any facilities, or any equipment.

You assume the risk of your participation in any activity, class, program, instruction, or event, including but not limited to weightlifting, walking, jogging, running, aerobic activities, aquatic activities, tennis, basketball, volleyball, racquetball, or any other sporting or recreational endeavor.

You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury, illness, damage, or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence of Trainer or otherwise.

RELEASE:
You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Trainer (and Trainer’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Trainer, whether active or passive, or any of Trainer’s affiliates, employees, agents, representatives, successors, and assigns.

This waiver and release of liability includes, without limitation, injuries which may occur as a result of (a) your use of any exercise equipment or facilities which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including personal training, (d) negligent hiring or retention of employees, and/or (e) slipping or tripping and falling while on any portion of a premises or while traveling to or from personal training, including injuries resulting from Trainer’s or anyone else’s negligent inspection or maintenance of the facility or premises.

INDEMNIFICATION:
By execution of this agreement, you hereby agree to indemnify and hold harmless Trainer from any loss, liability, damage, or cost Trainer may incur due to the provision of personal training by Trainer to you.

ACKNOWLEDGMENTS:
You expressly agree that the foregoing release, waiver, assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by the law in the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

You acknowledge that Trainer offers a service to his/her clients encompassing the entire recreational and/or fitness spectrum. Trainer is not in the business of selling weightlifting equipment, exercise equipment, or other such products to the public, and the use of such items is incidental to the service provided by Trainer.

You acknowledge and agree that Trainer does not place such items into the stream of commerce. This release is not intended as an attempted release of claims of gross negligence or intentional acts. You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk and indemnity agreement.

You are aware and agree that by executing this waiver and release, you are giving up your right to bring a legal action or assert a claim against trainer for trainer’s negligence, or for any defective product used while receiving personal training from trainer. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.

Consent(Required)

To the best of my knowledge, the information I have provided is true and I agree to the policies specified here.

Comments

This field is for validation purposes and should be left unchanged.