Consult Form

I understand that as part of this assessment:● I will be asked personal medical history questions and may be asked to perform a range of physical activities for the purposes of assessment of my physical fitness.● My permission to conduct this assessment is voluntary and any doubts or concerns will be clarified by the personal trainer who will use these results in designing an appropriate exercise program.● The personal trainer has no expertise in the field of medicine nor are they trained to detect serious medical problems and if a medical condition concerns me I will consult my doctor.● The information contained in this form is of private and confidential nature and will be handled in accordance with the relevant privacy acts and the privacy policy of the business. ● By agreeing to meet at a certain time, if you do not attend without and prior notice, one (1) session will be deducted. ● Type Your name below if you agree. *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

What time did you go to bed last night? (is this normal) *

Hour

Minute

Second

AM PM

What time did you wake up this morning? (is this normal) *

Hour

Minute

Second

AM PM