Name *

First Name

Last Name

Phone *

(###)

###

####

Do you have high cholesterol? *

Yes

No

Has your doctor ever said you have heart trouble? *

Yes

No

Has your doctor ever told you that you have a bone or joint problem (such as arthritis)? *

Yes

No

Has your doctor ever told you that your blood pressure was too high? *

Yes

No

Is there any reason, not mentioned thus far, that would not allow you to participate in a physical fitness program? *

Yes

No

Do you know how many calories you eat a day? *

Yes

No

Do you eat breakfast? *

Yes

No

Are you taking supplements? *

Yes

No

Do you often experience digestive difficulties? *

Yes

No

Do you feel that a properly structured nutrition and exercise program would benefit you? *

Yes

No

Have you reached and maintained your goals? *

Yes

No

Are you happy with the way you look and your health? *

Yes

No

How many meal do you eat per day? (not snacks) *

1

2

3

4

5

6

How long have you been exercising, consistently? *

0 to 6 months

6 months to 12 months

1 year to 2 years

Over 2 years

On a scale of 1 to 5, how serious are you about achieving your fitness goals? (1 being I really don't care and 5 being it is one of the most important things in my life) *

1

2

3

4

5

How many days a week do you plan on exercising? *

3

4

5

6

7

Please selcect your income range *

$0-$50,000

$50,000-$100,000

$100,000-$200,000

$200,000+

If accepted into our fitness coaching program are you able and ready to make a significant in your health and fitness goals in your future? *

YES

no

BUYER ACKNOWLEDGMENT AND ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF MARIO MEDINA FITNESS LLC. BUYER ACKNOWLEDGES THESE PHYSICAL ACTIVITIES INVOLVES THE INHERENT RISK OF PHYSICAL INJURIES OR OTHER DAMAGES, INCLUDING, BUT NOT LIMITED TO, HEART ATTACKS, MUSCLE STRAINS, PULLS OR TEARS, BROKEN BONES, SHIN SPLINTS, HEART PROSTRATION, KNEE/LOWER BACK/FOOT INJURIES AND ANY OTHER ILLNESS, SORENESS, OR INJURY HOWEVER CAUSED, OCCURRING DURING OR AFTER BUYER’S PARTICIPATION IN THE PHYSICAL ACTIVITES. BUYER FURTHER ACKNOWLEDGES THAT SUCH RISKS INCLUDE, BUT AR NOT LIMITED TO, INJURIES CAUSED BY THE NEGLIGENCE OF AN INSTRUCTOR OR OTHER PERSON, DEFECTIVE OR IMPROPERLY USED EQUIPMENT, OVER-EXERTION OF A BUYER, SLIP AND FALL BY BUYER, OR AN UNKNOWN HEALTH PROBLEM OF BUYER. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY INVOLVED WITH PARTICIPATION IN THE PHYSICAL ACTIVITIES, BUYER AFFIRMS THAT BUYER IS IN GOOD PHYSICAL CONDITION AND DOES NOT SUFFER FROM ANY DISABILITY THAT WOULD PREVENT OR LIMIT PARTICIPATION IN THE PHYSICAL ACTIVITIES. BUYER ACKNOWLEDGES PARTICIPATION WILL BE PHYSICALLY AND MENTALLY CHALLENGING, AND BUYER AGREES THAT IT IS THE RESPONSIBILITY OF BUYER TO SEEK COMPETENT MEDICAL OR OTHER PROFESSIONAL ADVICE, REGARDING ANY CONCERNS OR QUESTIONS INVOLVED WITH THE ABILITY OF BUYER TO TAKE PART IN MARIO MEDINA FITNESS LLC PHYSICAL ACTIVITIES. BY SIGNING THIS AGREEMENT, BUYER ASSERTS THAT HE OR SHE IS CAPABLE OF PARTICIPATING IN THE PHYSICAL ACTIVITIES. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY FOR NOT EXCEEDING HIS OR HER PHYSICAL LIMITS. TO AGREE TO THE TERMS ABOVE PLEASE SELECT "YES" BELOW *

Yes

No