Phone Number



Emergency Contact & Phone Number

Date Of Birth





Date Of Last Physical

Current Activity Level

If you have any diagnosed health problems list the condition(s).

If you are on any medications, please list them.

What additional therapies are being undertaken for the given health problems?

If you have any injuries, please list them.

What additional therapies are being undertaken for the given injury?

Has anyone of your immediate family developed heart disease before the age of 60?

Do any diseases run in your family?

Do you suffer from diabetes, asthma, high or low blood pressure?

What is your primary goal with your training?


Timeline for achieving your goal.

Have you trained with a personal trainer before?

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.
Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.
All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

Release Of Liability and Assumption Of Risk

I have volunteered to participate in a fitness program provided to me by Jeremy NyQuist, which may include, but may not be limited to, resistance training and aerobic or cardiovascular exercise. In consideration of Jeremy NyQuist’s agreement to instruct and train me, I do here now and forever release and discharge and hereby hold harmless Jeremy NyQuist and his respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from. THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT BELONGING TO Jeremy NyQuist OR TO MYSELF THAT MAY MALFUNCTION OR BREAK; (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT; (3) AND/OR NEGLIGENT INSTRUCTION OR SUPERVISION. I have been informed of, understand and am aware that any exercise program, whether or not requiring the use of exercise equipment, is a potentially hazardous activity. I also have been informed of, understand and am aware that any exercise and/or fitness activities involve a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity, or death. I have been advised that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed. If I have chosen not to obtain a physician’s consent prior to beginning this fitness program with Jeremy NyQuist, I hereby agree that I am doing so solely at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all fitness related activities and/or exercises in which I participate. I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST TRAINER FOR YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS. 2 This form is an important legal document that explains the risks you are assuming by beginning an exercise program. It is critical that you have read and understand this document