Pinnacle Fitness Center Health History Questionnaire

First Name *

Last Name *

Phone *

Email *

Address

City

State

Postal code

To change date range click on the year and month and select the corresponding date.

Date of birth

Emergency Contact *

Emergency Contact Phone *

Contact Relationship *

Active History

What is your present occupation?

Do you have injuries (bone, muscle, ligament, rods, pins, or plates) that may interfere with exercising?

What's motivating you to make a change in your health now?

What are you looking for in a fitness program?

List the medications you are presently taking.

Females Only

Do you take birth control? (If you answer yes, have you had problems with weight loss or metabolic issues?)

Do you have menstrual cycle irregularities? (Please explain if answering yes.)

Are you currently pregnant?

Yes

Liability Waiver

“I have enrolled in a program of strenuous physical activity including but not limited to weight training and the use of any aerobic conditioning equipment offered by Pinnacle Fitness Center, LLC. I affirm that I am in good physical condition and I do not suffer from any disability that would prevent or limit my participation in this exercise program. I release Pinnacle Fitness Center to use pictures taken of me exercising. I fully understand that I may injure myself as a result of my participation in the Pinnacle Fitness Center exercise program and I hereby release Pinnacle Fitness Center, LLC, its employees, contractors, and owners from any liability now or in the future, including but not limited to heart attacks, strokes, muscle strains, sprains, shin splints, broken bones, heat prostration, knee/ lower back/ foot injuries, and any other illness, soreness, injury, or sudden death however caused during or after my participation in this exercise program.”

By approving this agreement you signify that you understand and support the terms stated above.

Liability Signature *

Clear