Physical Focus, a private personal health fitness studio, provides private instruction by appointment, memberships and small group classes to accommodate a variety of interests. The following options are available to new clients
PLEASE SELECT AN OPTION BELOW:
All Personal Training appointments,
Private Pilates sessions and Group Class appointments must be canceled
at least twenty-four hours prior to the appointment or the session fee is forfeited. Memberships must
be canceled 30 days prior to the cancellation date. Personal Training, Private Pilates and Group Class
Sessions are nontransferable and nonrefundable unless previous arrangements with Physical Focus have
Monthly Membership fees shall be paid in advance. The first month's dues may be adjusted when the initial
sign-up begins after the first day of the month.
Each client will receive an invoice at the end of each month that includes all Personal Training, Private
Pilates sessions and Group Class appointments completed during that month and the next month's
membership dues if applicable. Payment is due 10 days from the invoice date. A 5% fee will be charged for
late payments. All New Clients must Pre-Pay for the first month of private training.
I. EXERCISE SCREENING QUESTIONNAIRE Please answer the following quesitons:
II. PERSONAL HEALTH HISTORY (SECTION I, II) Please answer the following quesitons:
Date of Birth
1 2 3 4 5 6 7 8 9 10 11 12 /
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908
Emergency Contact Phone
Personal Physician Phone
Date of Last Physical Exam
Do you have allergies? (please list)
Do you have any chronic or serious illnesses?
Have you been hospitalized in the last three years?
Has your physician prescribed any medications for you in the last 12 months?
Do you participate in regular exercise?
If yes, type of exercise:
times per week:
Have you ever experienced the following?
Do you have a stressful occupation?
Do you have control over your level of stress?
What are your primary LONG term exercise goals?
What are your primary SHORT term exercise goals?
What types of exercise do you enjoy?
What hobbies do you do regularly?
Do you take part in any sports or athletic activities?
What do you like MOST about exercise?
What do you like LEAST about exercise?
How much time do you want to spend exercising?
Discuss any past exercise experiences?
Have you ever worked with a personal fitness trainer or health consultant before?
Do you presently get massage, holistic care, body work, chiropractic care or physical therapy?
Do you have any questions on nutrition?
Is there anything that you would like to do better in your life and/or your sport?
GENERAL RELEASE AND WAIVER OF LIABILITY
Physical Focus, 140 Hot Springs Road, Montecito
The decisions whether or not to begin an exercise program is completely the client's decision. Physical Focus advises
each client to seek medical advice for the decision to start an exercise program. For that reason, Physical Focus, its
Owners, and its Independent Contractors, take no responsibility for the decision to begin or continue with an exercise
In recognition of the possible dangers connected with any physical activity, clients hereby knowingly and voluntarily
waive any right of cause of action of any kind whatsoever arising as the result of such activity from which any liability
may or could accrue to Physical Focus, its Owners or Independent Contractors. Clients with special medical conditions
or health concerns, (i.e. Asthma,, diabetes, heart disease) agree to inform their doctor of their decisions to begin an
exercise program and provide a signed medical release form.
I have carefully read this release and fully understand its contents. I am aware that this agreement contains a release
of liability, arising out of the negligence of Physical Focus, its owners, or independent contractors or that of a third
party, and is a contract between myself and Physical Focus, its independent contractors and its facility. This release
supplements any membership contract I may hereafter execute with Physical Focus.
After reading this release, please write the following sentence on the lines below and print your
name and date.
"I have carefully read this release and fully understand its contents. [your name & date]"
All new clients must pre-pay for their first month of Private Personal Training and Pilates Appointments and
Membership if applicable. The number of Private Appointments that will take place during the first month of training
will be estimated during the initial client interview. This estimated amount will be due at the completion of the first
private appointment. At the end of the first month, the client will be credited for any unused sessions or billed for any
additional sessions. After the first month, the private training sessions will be billed at the end of the month with the
next month's membership if applicable.
We do all our billing electronically, so please provide your full name and a valid email address where you would like your monthly invoices sent. Thank You.
Please enter the phrase below to continue: