Physical Readiness Questionnaire Name * First Name Last Name Email * Phone * (###) ### #### Do you have high cholesterol or are you currently being treated for it? * Yes No Has the doctor ever said that you have heart trouble? * Yes No Do you have any bone or joint issues? Be specific with past injuries, pain, doctor diagnosis, etc * Has your doctor ever told you that your blood pressure was too high or are you being treated for high blood pressure? * Yes No Are you over the age of 65 and not accustomed to vigorous exercise? * Yes No Is there any reason, not mentioned thus far, that would not allow you to participate in a physical fitness program? * BUYER ACKNOWLEDGMENT AND ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF The Movement by Riddick LLC. BUYER ACKNOWLEDGES THEIR PHYSICAL ACTIVITIES INVOLVES THE INHERENT RISK OF PHYSICAL INJURIES OR OTHER DAMAGES, INCLUDING, BUT NOT LIMITED TO, HEART ATTACKS, MUSCLE STRAINS, PULLS OR TEARS, BROKEN BONES, SHIN SPLINTS, HEART PROSTRATION, KNEE / LOWER BACK / FOOT INJURIES AND ANY OTHER ILLNESS, SORENESS, OR INJURY HOWEVER CAUSED, OCCURRING DURING OR AFTER BUYERS PARTICIPATION IN THE PHYSICAL ACTIVITIES. BUYER FURTHER ACKNOWLEDGES THAT SUCH RISKS INCLUDE BUT NOT LIMITED TO, THE NEGLIGENCE OF A INSTRUCTOR OR OTHER PERSON, DEFECTIVE OR IMPROPERLY USED EQUIPMENT, OVER EXERTION OF A BUYER, SLIP AND FALL BY A BUYER, OR AN UNKNOWN HEALTH PROBLEM. BUYER AGREES TO ASSUME ALL RISKS AND RESPONSIBILITY INVOLVED IN THE PARTICIPATION OF PHYSICAL ACTIVITIES, BUYER AFFIRMS THAT BUYER IS IN GOOD PHYSICAL CONDITION AND DOES NOT SUFFER FROM ANY DISABILITY THAT WOULD PREVENT OR LIMIT PARTICIPATION IN THE PHYSICAL ACTIVITIES. BUYER ACKNOWLEDGES PARTICIPATION WILL BE PHYSICALLY AND MENTALLY CHALLENGING, AND BUYER AGREES THAT IT IS THE RESPONSIBILITY OF THE BUYER TO SEEK COMPETENT MEDICAL OR PROFESSIONAL ADVICE, REGARDING ANY CONCERNS OR QUESTIONS INVOLVED IN THE ABILITY OF BUYERS TO TAKE PART IN EL PROGRAM LLC PHYSICAL ACTIVITIES. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY IN NOT EXCEEDING HIS OR HER PHYSICAL LIMITS. * I Agree Sign Below * First Name Last Name How is your energy level throughout the day? Do you ever feel weak, fatigued, or sluggish? * How many times do you eat a day? Tell us about your nutritional habits * Are you taking any supplements? * Yes No Do you ever crave sugary foods? * Yes No Do you feel that you need to boost your immune system? * Yes No Do you often experience digestive difficulties? * Yes No Do you feel that a properly structured exercise and nutrition program would benefit you? * Yes No Have you ever reached and maintained your fitness goals? * Yes No Have you ever worked with a certified personal trainer? If so, how was that experience? * Are you happy with the way you look and your feel? * Yes No How many times a week would you like to work with a personal trainer? * What days of the week and times frames are best for you to exercise? * Which types of training are you most interested in? * Aerobics Strength Training Yoga / Flexibility & Mobility Pilates / Core What are your fitness and health goals? Be specific: * Why are these goals important to you? * Have you tried to reach these goals before? How many times have you tried? * Thank you!
