Vitality Fitness

Medical History Form

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First Name_____________ Last Name_______________ e-mail _____________

Date of Birth________________ Phone #’s ___________ cell ____________

How were you referred to Vitality Fitness? ______________________________

Level of Activity (check one ) :

__ Sedentary __ Mildly Active __ Active __ Very Active

Notes on Activity____________________________________________

__________________________________________________________

Hypertension :

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 __________________________________________________

Smoking :

Do you smoke?

If no, did you ever smoke? How long ago? ___ ___yes ___no

If yes, how much did/do you smoke? ___________________________

If you smoke, do you want to quit? ___ yes ___ no

 

Heart :

Have you ever been diagnosed with heart problems? ___ 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 ____________________________________________________

Joints :

Have you ever been diagnosed with joint or soft tissue problems? ___yes ___ no

If yes, explain_________________________________________________________

____________________________________________________________________

Do you have problems with your:

Upper Back ____ yes ___ no
Lower Back ___ yes ___ no
Neck ___ yes ___ no
Shoulders ___ yes ___ no
Elbows ___ yes ___ no
Wrists ___ yes ___ no
Hips ___ yes ___ no
Knees ___ yes ___ no
Ankles ___ yes ___ no

If yes, explain _____________________________________________________

_________________________________________________________________

Physician:

Name _________________________ 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

Dated: __________________

Signature: _______________________________________
Participant: ___________________________________
Address: ___________________________________
_________________________, _________________________ __________

In case of an emergency, please call ___________________________________ (Relationship: _________________________ ) at ______________ Ext. ______ (Day), or ______________ Ext. ______ (Evening).