Medical History Form | South Tampa Personal Training

First Name

Last Name

e-mail

Date of Birth

Phone #

Cell

How were you referred to Vitality Fitness?

Level of Activity (check one) :

Sedentary
Mildly Active
Active
Very Active

Notes on Activity

Have you ever been diagnosed with high blood pressure?

Yes
No

Have you ever been prescribed medication to control high blood pressure?

Yes
No

If Yes, explain

Do you smoke?

Yes
No

If no, did you ever smoke?

Yes
No

If yes, how long ago and how much did/do you smoke?

If you smoke, do you want to quit?

Yes
No

If you smoke, do you want to quit?

Yes
No

Have you ever been diagnosed with heart problems?

Yes
No

Do you suffer from chest pain?

Yes
No

Do you suffer from chest pain?

Yes
No

Do you ever feel faint or have spells of dizziness?

Yes
No

Have you ever been prescribed medication for heart problems?

Yes
No

If Yes, explain

Have you ever been diagnosed with joint or soft tissue problems?

Yes
No

If Yes, explain

Do you have problems with your: (Check all that apply)

If yes, explain

Physician Name

Physician Phone Number

Medications currently being used

RELEASE OF LIABILITY- READ CAREFULLY – THIS AFFECTS YOUR LEGAL RIGHTS

In exchange for participation in the activity of personal training, weight training, cardiovascular exercise, and general fitness organized by Vitality Fitness, Inc. (“Vitality Fitness”), of 1706 S. Dale Mabry, Tampa, Florida, 33629 and/or use of the property, facilities and services (trainers) of Vitality Fitness, I agree to the following:

1. I agree to observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by Vitality Fitness, or the employees, representatives or agents of Vitality Fitness.

2. I recognize that there are certain inherent risks associated with the above described activity and I assume full responsibility for personal injury to myself and further release and discharge Vitality Fitness for injury, loss or damage arising out of my use of or presence upon the facilities of Vitality Fitness, whether caused by the fault of myself, Vitality Fitness or other third parties.

3. I agree to indemnify and defend Vitality Fitness against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my use of or presence upon the facilities of Vitality Fitness.

4. I agree to pay for all damages to the facilities of Vitality Fitness caused by my negligent, reckless, or willful actions.

5. Any legal or equitable claim that may arise from participation in the above shall be resolved under Florida law.

I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARY SURRENDER CERTAIN LEGAL RIGHTS

Date:

Signature: