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Physical Focus Contract

Please fill out the following forms completely. The information you provide will remain private and confidential.

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:
ONE-ON-ONE TRAINING & 24 HOUR KEY CLUB MEMBERSHIP
combines the benefits of one-on-one training with our 24 Hour Key Club Membership. Members will be given a code to access the studio 24 hours a day, 7 days a week.
ONE-ON-ONE TRAINING only
allows use of the studio only during scheduled personal training and private Pilates appointments.
24 HOUR KEY CLUB MEMBERSHIP only
accommodates self disciplined exercisers wanting a membership to our studio without weekly private appointments and permits unlimited use of the studio. Members will be given a code to access the studio 24 hours a day, 7 days a week.
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 been made.

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:

Do you currently experience chest pains that come on at rest or with exertion? yes  no
Has a physician diagnosed these pains? yes  no
diagnosis:
Have you ever had a heart attack? yes  no
last blood pressure reading:
Do you have diabetes? yes  no
treatment: none  pills  diet  insulin
Are you short of breath at rest, at night in bed or after very mild exertion? yes  no
Do you have any ulcers or cuts on your feet that have not healed? yes  no
In the past six months, have you lost 10 pounds or more without trying? yes  no
Do you feel pain in your buttocks or the backs of your legs (thigh or calves) when you walk? yes  no
Do you often have fast, irregular or very slow heart rate while you are resting? yes  no
Are you currently being treated for a heart or circulatory condition? yes  no
Vascular Disease High Blood Pressure
Valvular Heart Disease Stroke
Congestive Heart Failure Blood Clots
Angina Poor Circulation to Legs
Other:
Have you ever (as an adult) had a fracture of the hip, spine or wrist? yes  no
Have you fallen (for any reason) more than twice in the past year? yes  no
II. PERSONAL HEALTH HISTORY (SECTION I, II)

Please answer the following quesitons:
Name
Date of Birth  /   / 
Phone (work)
Phone (home)
Emergency Contact
Emergency Contact Phone
Personal Physician
Personal Physician Phone
Section I
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?
Section II
1. Have you been told that you have any of the following:
High Blood Pressure you family relationship: 
Diabetes you family relationship: 
Heart Disease you family relationship: 
Stroke you family relationship: 
Angia you family relationship: 
Arterioschlerosis/Atherosclerosis you family relationship: 
Rheumatic Fever Coronary Occlusion you family relationship: 
Other you family relationship: 
Have you ever experienced an abnormal resting or stress ECG? yes  no
when?
Has your doctor ever restricted your physical activity? yes  no
when? how? why?
Have you ever been told that you have high cholesterol? yes  no
Do you smoke? yes  no
How many per day/per week?
Has your weight fluctuated more than a few pounds in the last twelve months yes  no
If yes, was this weight the result of diet and/or exercise? yes  no
Have you ever experienced chest pain or tightness as a result of physical activity? yes  no
Have you experienced unexplained rapid heartbeats or skipped beats? yes  no
Do you have ever experienced a shortness of breath during physical activity with others your age? yes  no
Do you ever experience pain or cramps in your legs? yes  no
Do you experience dizziness during vigorous physical activity? yes  no
Section III
Do you participate in regular exercise? yes  no
If yes, type of exercise:
times per week:   minutes/sessions:
Have you ever experienced the following?
Vascular Disease Joint Injuries
Muscle or ligament strain/sprain Herniated disc
Back injury Low back pain
Spinal surgery Other
please elaborate:
Do you have a stressful occupation?
Do you have control over your level of stress?
Section IV
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 program.

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]"
BILLING INFORMATION
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.

Please print your name and the address you would like the invoices to be sent. Thank you.
First Name
Last Name
Email Address
Street Address
City
State/Zipcode   /  
140 Hot Springs Road Montecito, California (805) 695-0450