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Have you ever had any form of heart disease or do you have a known heart condition?
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Have you ever experienced shortness of breath or chest pains?
 Yes No
Do you have or do any of the following pertain to you?
 Diabetes High Blood Pressure Cigarette Smoking Heart Disease in Family Taking Current Medications Do You Exercise Regularly?
If yes, please explain below:

Do you have any problems or issues with the following areas? Lower Back Knees Neck/ Shoulders Hip/ Pelvis Other
If yes, please explain below:

INFORMED CONSENT
I wish to participate in the exercise and training program offered by J. NyQuist Fitness. I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. I agree that J. NyQuist Fitness shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge The J. NyQuist Fitness and its owners, employees, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators and assigns. I understand that my purchase of J. NyQuist Fitness training is non-refundable.

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