Medical Questionnaire

General Instructions

The Medical and Lifestyle Questionnaire is designed for you to report any medical conditions or concerns that may impact your fitness program and to measure your interest in a whole-body fitness program. If you are working with one of our trainers, this is a required document. There are no right or wrong answers. We want to know more about you so that our trainers can design a program that fits with your lifestyle and determine whether there are activities or exercises which would be inappropriate or which would require the guidance of your doctor.

Fill out this form as completely as possible. If you have any questions, do not guess. Ask one of our trainers or your family physician for assistance. If you answer yes to more than one of the questions below, you should be evaluated by a physicial before starting a physical fitness workout with one of our trainers.

Before participating in any activities, fitness programs, or sports activity with PhiferFitness.com, you must have a completed waiver on file. Please read the following contract carefully.

Contract

Before you begin this exercise program, and before you follow an of the advise, instruction or any other recommendations in the Web site and email, you should first consult with your doctor and have a physical examination. The recommendations, instructions and advice contained within this Web site are in no way intended to replace or be construed as medical advice. If you have chosen not to obtain a physician’s advice, examination and permission prior to beginning this program with Phifer Fitness, you are doing so at your own risk.

By accepting the terms of this agreement, you are stating that you fully understand that you are solely responsible for the way that the information within this Web site is perceived and utilized and do so at your own risk. By accepting the terms of this agreement, you are acknowledging that all types of exercise are potentially hazardous activities and may cause injury and even death. You are stating that you are voluntarily participating in these activities, including but limited to weight and/or resistance training, cardiovascular training and flexibility training. You acknowledge and agree that no warranties or representations have been made to you regarding the results you will achieve from this program. You understand that results vary from one individual to another.

By accepting the terms of the agreement, on behalf of yourself, your heirs, assigns, insurance companies, executors and administrators, you are acknowledging that you do here and forever waiver, release and discharge and hereby hold harmless Phifer Fitness and their respective agents, heirs, assigns, contractors and employees from any and all claims, demands, damages, rights of actions or causes of action, present or future, arising out of or connected with your participation in this exercise program including injuries resulting therefrom.

I, the undersigned, acknowledge that I am applying to Phifer Fitness for instruction in a program of physical activity and possible personal body contact including but not limited to possible strenuous exercise, use of weights, balls, explore boards and suspension swings.

As a condition to my being permitted to participate in Phifer fitness programs, I

1. Can you be classified as any of the following?

 yes no

 yes no

 yes no

2. Does either of the following occur in your family history?

 yes no

 yes no

3. Do you currently smoke cigarettes?
 yes no

4. Do either of the following apply to you with regards to hypertension?

 yes no

 yes no

5. Do any of the following apply to you with regards to hypercholesterolemia?

 yes no

 yes no

 yes no

6. Do any of the following apply to you with regards to diabetes mellitus?

 yes no

 yes no

 yes no

7. Do any of the following apply to you with regards to a sedentary lifestyle?

 yes no

 yes no

 yes no

8. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
 yes no

9. Do you feel pain in your chest when you do physical activity?
 yes no

10. In the past month, have you had chest pain when you were not doing physical activity?
 yes no

11. Do you lose your balance because of dizziness or do you ever lose consciousness?
 yes no

12. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
 yes no

13. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
 yes no

14. Do you know of any other reason why you should not do physical activity?
 yes no

15. Full Name: