Genesis Fitness: Client Intake Form
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Email *
Untitled Title
First Name *
Last Name *
Phone Number *
Age *
Height *
Birthday *
MM
/
DD
/
YYYY
Do you sit or stand at work? *
Do you have any children? If so, how many? *
Have you had any surgeries? *
Are you currently taking any medications? *
Are you allergic to any medications? *
Do you or have you had any eating disorders? *
Are you currently taking any supplements, vitamins or supper supplements? *
Are there any foods that may cause you an upset stomach?  *
Do you have a history of bloating or constipation? *
How many bowel movements do you have daily? *
How much water do you drink on a daily basis? *
How often do you work out? *
Do you work out at the gym or at home? *
If you workout at home, what gym equipment do you own? (type "N/A" if not applicable) *
What is your cardio protocol typically? *
What are your short term fitness and health goals?  *
What are your long term fitness and health goals?  *
If I have any physical limitations, these should be indicated or made known to Genesis Fitness & Wellness, prior to an exercise/training session. I understand that the fitness professionals of this company are not license medical professionals and that sessions are meant to be physical and educational in content. I further understand that none of the information conveyed in a session is meant to be taken as a diagnosis and that I should see a physician for any medical condition.
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I (Buyer, Member, Parent, Spouse, or Guest, as applicable) agree that if I engage in any physical exercise or activity or use any facility on a club's premises or off-site, I do so at my own risk. This includes, without limitation, my use of the equipment, parking area, or sidewalk.
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I agree that I am voluntarily participating in these activities and using the equipment and facilities and assuming all risk of injury or my contraction of any illness or medical condition that might result there from, or any damage, loss or theft of any personal property. I agree on behalf of myself (and my personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge us (and our affiliates, employees, agents, representatives, successors and assigns) from any and all claims or causes of action arising out of our negligence. This Waiver and Release of all liability includes, without limitation, injuries which may occur as a result of (a) my use of any facility or its improper maintenance, (b) my use of any exercise equipment which may malfunction or break, (c) our negligent instruction or supervision, and (d) my slipping and falling while in any club or on the surrounding premises.
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I acknowledge that I have carefully read this waiver and release and fully understand that it is a release of all liability, in addition, I do hereby waive any right that I may have, by or on behalf of myself, my spouse or any child (minor or otherwise), to bring a legal action or assert a claim for injury or loss of any kind against us for negligence or arising out of or relating to participation by myself, my spouse or child in any of the activities, or use of the equipment, facilities or services basic fitness PT provides as described in this paragraph, or on account of any illness or accident, or damage to or loss of my personal property.
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To acknowledge this full form questionnaire, type in your FULL NAME below which will act as your signature.  *
A copy of your responses will be emailed to the address you provided.
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