Surge Fitness - Personal Training and Fitness in New York City NY


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Jason Keigher
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CONTACT INFORMATION
Name:
Street address:
City:
State/Province:
Zip/Postal code:
Country:
Email address:
Phone:

PERSONAL INFORMATION
Sex: Male Female Age: Height: Weight:
What is your resting heart rate? What is your blood pressure?
What is your perception of your current level of fitness, muscular strength, aerobic capacity, flexibility, balance and coordination? (be very specific)
EXERCISE HISTORY
Do you currently exercise on a regular basis? yes no
If yes, describe the frequency, intensity, time and type of exercise routine:
How long have you been exercising regularly? years months
HEALTH & FITNESS GOALS
What are your health and fitness goals? (be very specific)
What areas of fitness interest you? Strength training Body Toning and Shaping Weight Loss Flexibility/Stretching Yoga Pilates Body Building Pre/Post Natal Postural Correction Nutrition Other:
Where will you workout? Gym/Health Club Home Other: What type of fitness equipment will you have access to? (weights and cardiovascular) How much time will you devote to an exercise program? days per week minutes per day What exercises do you most and least enjoy? List any injuries that may limit your ability to follow an exercise program.
DIET AND NUTRITION How would you describe your eating habits? healthy unhealthy erratic What would you like to change about your eating habits? Are you trying to diet or lose weight? yes no If yes, how much would you want to lose? lbs. How many meals do you eat each day? What is you favorite protein, carbohydrate and junk food? (list all three) MEDICAL HISTORY When was the last time you had a physical examination (mm/dd/yy)? Do you have:
High blood pressure?	yes no
High cholesterol?	yes no
Diabetes?	yes no
Known heart disease?	yes no
A heart murmur?	yes no
Chest pain during physical activity?	yes no
Irregular heart beat or palpitations?	yes no
Lightheadedness or fainting spells?	yes no
Unusual shortness of breath?	yes no
Cramping pains in legs or feet?	yes no
Emphysema?	yes no
Thyroid or kidney disorders?	yes no
Epilepsy?	yes no
Asthma?	yes no
Back pain?	yes no
Other joint pain?	yes no
Muscle pain or an injury?	yes no
Cancer?	yes no
Osteoporosis?	yes no
Are you currently under a doctor's care?	yes no
Have you recently been hospitalized?	yes no
Do you smoke?	yes no
Are you pre/postnatal?	yes no
Do you drink alcohol more than three times per week?	yes no
Do you consider your stress level to be high?	yes no

Do you have a grandparent, parent or sibling who, prior to age 55, has had:

A heart attack?	yes no
A stroke?	yes no
High blood pressure?	yes no
High cholesterol?	yes no
Weight (obesity) problems?	yes no

If you answered yes to any of the above questions, please explain in detail:

List any medications you take on a regular basis. Include vitamins and supplements.

List all additional medical information that was not already covered.

RELEASE OF LIABILITY

Please read the following terms and agreements and indicate that you accept the terms below. By choosing "I accept" below you are agreeing to the terms below.

As with all programs, techniques, and materials related to health, exercise and fitness, you are strongly urged to consult a physician or other appropriate health-care professional before using any of the products and services made available by or through Surge Fitness and its Website. If you have chosen not to obtain a physician's permission prior to beginning this program with Surge Fitness then you are doing so at your own risk. Surge Fitness cannot guarantee that such products and services will be safe, effective or suitable for everyone. For that reason, all such products and services, and the programs, techniques and materials embodied in such products and services, are offered without warranties or guarantees of any kind, express or implied, and Surge Fitness disclaims any liability, loss or damages that may result from their use.

By accepting the terms of this agreement, you are stating that you fully understand that you are solely responsible for the way that the information within this Website and within all forms of communication received from Surge Fitness is perceived and utilized and do so at your own risk. By accepting the terms of this agreement, you are acknowledging that all types of exercise are potentially hazardous activities and may cause injury and even death. You are stating that you are voluntarily participating in these activities. By accepting the terms of this agreement, on behalf of yourself, your heirs, assigns, insurance companies, executors and administrators, you are acknowledging that you do hereby waive, release and forever discharge Surge Fitness and their respective heirs, directors, officers, agents, employees, representatives, successors and assigns, administrators, executors, and all others from any and all responsibilities or liability from injuries or damages resulting from or connected with your participation in any of the Surge Fitness exercise programs whether arising from the negligence of the releasees or otherwise. All of the information provided on the Surge Fitness website and through any Surge Fitness communication is made without warrantee or guarantee, express or implied. This website (and all communication received from Surge Fitness) provides Surge Fitness's opinion in regards to the subject matter contained herein. You acknowledge and agree that no warranties or representations have been made to you regarding the results you will achieve from this program. You understand that results vary from one individual to another.

Surge Fitness offers no warranties or representations regarding the advice, instructions, e-mail advice or any other information contained in this Website. Surge Fitness disclaims any responsibility and all warranties, representations and conditions regarding the site or the information, including all implied warranties and conditions of merchantability, fitness for a particular purpose, non-infringement, whether expressed or implied, or arising from a course of dealing, usage or trade practice and shall not be liable for any damages, claims, liabilities, costs or obligations including any direct, indirect, special, incidental, punitive or consequential damages (collectively the "damages") whatsoever and howsoever caused, arising out of or in connection with the use or misuse of the site or the information whether such damages arise in contract, tort, negligence, equity or statute law or by way of any other legal theory regardless of whether such damages could have been foreseen.

You agree that all the personal information (e.g. your medical history) provided by you to Surge Fitness is true and accurate. And, you agree to notify Surge Fitness if any of your personal information changes in the future while you are still a member of Surge Fitness.

The Information on the Site (and within any forms of communication from Surge Fitness) is provided for information and education purposes only. The Information is not intended to be and does not constitute healthcare or medical advice. The Information is not intended to be and must not be used for diagnosis. The Information on this website is general in nature and is not specific to you. You are responsible for the way this information is perceived and utilized, and do so at your own risk. You should not make any decision regarding treatment and/or medication based on any of the Information on this Site. Any decision concerning your health, treatment and/or medication should be made in consultation with a qualified healthcare professional.

Any nutritional information on the Site is intended for informational and educational purposes only. Nutritional information is provided by a Surge Fitness personal trainer, not by a registered dietician or other medical professional.

I accept I do not accept

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Thank you for filling out this questionnaire. We will contact you by phone or email once we receive your information. If you have any questions please call us at 917-549-8998.

It takes about 7-10 days once we receive payment to complete your customized fitness program. To expedite this process, please send the $99 payment via PayPal.com to info@surgefitness.com. If you don't have a paypal account, you can send a check or money order to:

    Jason Keigher
    970 Park Avenue
    Elizabeth NJ 07208