Main menu
Meet the Team
Alexis C. Gaston
Jen Bricker Simpson
Jaqui Griffith
Chris Maignan
Faith Maignan
Marney Richards
Dwan Riggins
Savannah Williams
Coaching
Adventure Training
Corrective Exercise and Movement Optimization - FMS Screen
Fit Kids
just eat fit
Just Live Fit
Sports Performance Training
Virtual Training
Yoga
90 Day Challenge
Group X
Body Work
AIS - Active Isolated Stretching
ART - Active Release Technique
Kinesio Taping
Massage Therapy
MELT Method
Shout Outs
Events
Birthday Parties
Corporate Events
Take the Challenge
Waiver
Complete the client waiver below to get started on your personal fitness training.
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip Code
*
Home Phone
*
Business Phone
Occupation
*
Age
*
Birthday
*
Email
*
Confirm Email*
*
Physician's Name
Physician's Phone
Emergency Contact
*
Emergency Contact's Phone
*
I was referred by:
Health & Fitness Program
*
Select One
AIS Stretching
21-Day Transformation
Kinesio Taping
90-Day Challenge
Group X Workouts
Massage Therapy
MELT Method ®
Personal Fitness Training
Specialty Program
Other
Identify the program that you are most interested in.
Reason for Your Visit
Injury and Medical Treatment History
*
Date of Last Physical
*
Physical Activity Readiness Questionnaire
Have you ever had any form of heart disease?
*
Yes
No
Have you ever experienced shortness of breath or chest pain?
*
Yes
No
Do you often feel faint or have spells of dizziness?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have high cholesterol?
*
Yes
No
Do you currently smoke or have you smoked in the past?
*
Yes
No
Do you have diabetes?
*
Yes
No
Do you have a family history of heart disease?
*
Yes
No
Do you have an abnormal resting EKG?
*
Yes
No
Are you active?
*
Yes
No
Has a doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be made worse with exercise?
*
Yes
No
Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?
*
Yes
No
Are you over age 65 and not accustomed to vigorous exercise?
*
Yes
No
I have read and answered the “Physical Activity Readiness Questionnaire.” I understand that if I answered yes to any question, vigorous exercise or exercise testing should be postponed. Medical clearance may be necessary.
*
Yes
No
Additional Health History
How often are you active or do you exercise?
*
Describe your typical activities or exercises.
*
Are you currently taking any medication?
*
Yes
No
Do you have any allergies?
*
Yes
No
Do you have any problems in the following areas? Select all that apply.
*
Knees
Low Back
Neck/Shoulders
Hips/Pelvis
Flexibility
If you answered "Yes" to any of the questions above, please explain.
*
Are you currently under the care of a health professional?
*
Yes
No
Health Care Provider's Name
Health Care Provider's Phone
Just Get Fit Media Release
Signature
*
Date
*
Waiver of Liability and Release
Signature
*
Initials
*
Date
*
Submit
Website
