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New Client Forms

Each new client is required to fill out the form below and print the Physician Statement PDF for their primary care physician to sign. These questions are important in designing a program that works for you.

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Personal Contact Information
Name (Required)*
First Last
Sex*
- Male
- Female
Age*
Weight
Height
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone (work)
Phone (Home)*
Is it okay to contact you at work?
- Yes
- No

Wellness Program
What days and times do you prefer to participate in your exercise program?*
Briefly describe your exercise and diet history:*
What are your short and long-term goals for improving you health?*
What specifically do you want from me, your personal trainer?*
Have you ever had a personal trainer before?*
- Yes
- No

Primary Care Physician
Physician Name*
Physician Phone*
Emergency Contact
Name*
First Last
Relationship*
Phone*
Health Screening Questions
Are you taking any medications or drugs?*
- Yes
- No
Please list all medications or drugs currently taking.*
Does your physician know you are participating in this exercise program?*
- Yes
- No
Describe your exercise program now:*
Do you know or have you had in the past a history of heart problems, chest pain or stroke?
- Yes
- No
Increased blood pressure?*
- Yes
- No
Any chronic illness or condition?*
- Yes
- No
Difficulty with physical exercise?*
- Yes
- No
Recent surgery (last 12 months)?*
- Yes
- No
Pregnancy (now or within the last 3 months)?*
- Yes
- No
Muscle, joint, or back disorder, or any previous injury still affecting you?*
- Yes
- No
Diabetes or thyroid condition?*
- Yes
- No
Cigarette smoking habit?*
- Yes
- No
Obesity (more than 20 percent over ideal body weight)?*
- Yes
- No
Increased blood cholesterol?*
- Yes
- No
Hernia, or any condition that maybe aggravated by lifting weights?*
- Yes
- No
If yes to any above, please explain.

Consent Agreement
RELEASE – WAIVER- INDEMNITY*
Whereas, Birgitt Haderlein, doing business as To Fit You, has offered her fitness Studio for use by certain persons at their own discretion and at times mutually agreed upon;

Whereas, the Undersigned (hereinafter referred to as “User”) desires to use the To Fit You Fitness Studio, including all equipment at User’s own discretion;

Whereas, To Fit You may provide User with a training program designed to improve User’s health and well being;

Whereas, User understands and acknowledges that while an exercise program is intended to improve health and well being of User, it entails certain risks;

In consideration of the above, User hereby agrees to the following:
1. User wishes to use the Fitness Studio and any equipment at User’s own discretion at times mutually agreed upon;
2. User understands and agrees that the use of the facility is personal to User and User will not under any circumstances invite any other person to the facility without the express written permission of To Fit You. Any violation of this paragraph shall cause User’s privilege for use of the Facility to be revoked, and User will become solely responsible for any injury or death to the other person regardless of the cause or circumstances;
3. User understands that the facility or User’s exercise program may not be supervised and agrees to an assumption of the risks entailed in use of an unsupervised facility including for any defective, broken or substandard equipment;
4. User understands that a training program entails risks that may or may not be apparent to To Fit You or User. User acknowledges that engaging in a training program may entail risk of injury or death and he/she accepts the risk of the training program designed by To Fit You;
5. User has read this Release – Waiver – Indemnity form and states that he/she is in good health and has no condition that would limit or prohibit participation in a training program.
6. User understands that other activities or personal training sessions by other Personal Trainers may be ongoing. User understands that those Personal Trainers do not have any obligation to supervise User, and any solicited or unsolicited advice from said Personal Trainers does not create any liability for injury or death to User for said advice;

IN CONSIDERATION OF THE ABOVE, USER AND HIS/HER ESTATE, BENEFICIARIES OR OTHER PERSONS ON HIS/HER BEHALF AGREE TO RELEASE TO FIT YOU, ANY OTHER PERSONAL TRAINER AND THEIR CLIENTS FROM ANY AND ALL LIABILITY FOR INJURIES OR DEATH THAT MAY OCCUR FROM USE OF THE FACILITIES OR ENGAGING IN A TRAINING PROGRAM.

USER, USER’S ESTATE, BENEFICIARIES OR OTHER PERSONS FURTHER AGREE TO DEFEND AND INDEMNIFY BIRGITT HADERLEIN, TO FIT YOU, ANY OTHER PERSONAL TRAINERS AND THEIR CLIENTS FROM ANY AND ALL CAUSES OF ACTION INCLUDING BUT NOT LIMITED TO BREACH OF CONTRACT, NEGLIGENCE, GROSS NEGLIGENCE, AND DEFECTIVE OR BROKEN EQUIPMENT, AND TO LOOK TO USER’S OWN INSURANCE POLICIES, IF ANY, FOR ANY AND ALL CLAIMS WHETHER SOUNDING IN TORT, TRESPASS OR CONTRACT.

USER ACKNOWLEDGES THAT HE/SHE UNDERSTANDS THIS RELEASE – WAIVER –INDEMNITY FORM AND HAS ENTERED IT VOLUNTARILY WITHOUT RESERVATION.

Acknowledgement*
Consent*
Congratulations on taking a big step toward improving your fitness level by hiring me as your personal fitness trainer. As your fitness trainer I will guide you through exercise sessions that will incorporate the major components of fitness; cardiovascular, muscular strength and endurance, and flexibility. It is your responsibility to give me consistent feedback regarding your physical response to the exercise program and inform me of any changes in your health that might affect your participation in the exercise sessions.

All workouts will be gradual and progressive in nature. During a cardiovascular workout your intensity level will be monitored by your heart rate response to the exercise as well as your perceived level of exertion. Each CV workout will end with a thorough cool down period. Strength workouts will be designed based on an assessment of your current level of strength and your goals. Flexibility exercises will be incorporated into your overall program.
In submitting this form you give your consent that you understand that this is not a medically supervised fitness program and you agree to look to your primary physician for medical care.

I release any and all claims for myself and my heirs against Birgitt Haderlein for any illness or injury which may directly or indirectly result from my participation in a personal fitness program supervised by her.
I agree to release any and all claims
Phone
This field is for validation purposes and should be left unchanged.

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Why To Fit You?

You have what it takes to achieve a wonderful level of health, fitness and vitality. Too many people leave their best self in the gym when they walk out, and some of us don’t have the chance to make it to the gym. The focus, fun and energy get watered down by hectic schedules, traffic, deadlines and personal concerns.

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To Fit You, 1750 Seamist Dr. #170 Builiding 1 Houston, TX 77008 | P: 713-410-3376

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