Questionnaire - I.Q. Fit

Items marked with an * are required. We highly value the security and privacy of your personal information. It will never be shared with anyone.

NOTICE: Please allow between 30 and 60 minutes to fully complete the form below. No data will be submitted until you click "submit" on the last page.

First Name *

Last Name *

Address *

Apt. Suite#, Etc.

City *

State *

Zip Code *

Phone *

Email *

D.O.B. *

Medical Health History

1) Medications and Supplements, please list and specify type, dosage and reason for taking?

2) Do you have any food allergies? *

Yes

If yes, please list:

3) Do you get heart burn? *

Yes

4) Do you have exercise-induced asthma? *

Yes

5) Do you have GI issues? *

Yes

If yes, please please describe what and how often:

6) Do you have migraines? *

Yes

7) Do you have cancer? *

Yes

8) Do you have diabetes? *

Yes

9) Do you hit a "wall" or get "brain fog" at any time during the day, 2 or more times per week? *

Yes

10) Sleep A - Do you wake up feeling rested most mornings? *

Yes

11) Sleep B - Do you feel like you need a nap in the middle of the day, more than 2 or more time per week? *

Yes

12) Stress A - Is your occupational stress load higher than 8 out of 10 in terms of average stress level? *

Yes

13) Stress B - Is your home life stress load higher than 8 out of 10 in terms of average stress level? *

Yes

14) Nutrition - Please list as best you can every single food and drink item you consumed in the last 24 hour period (don't worry, we won't judge you).

15) Have you ever had a heart attack? *

Yes

16) Has a physician ever said you have heart trouble? *

Yes

17) In the past 3 months, approximately how many times have you experienced any pain, pressure or discomfort in your chest?

18) Has a physician ever told you that you had an abnormal EKG indicating an enlarged heart? (A condition called ventricular hypertrophy.) *

Yes

19) Do you receive regular care from a chiropractic doctor? *

Yes

If yes, how often?

For what condition(s)?

20) Do you receive regular care from a osteopathic manipulating doctor? *

Yes

If yes, how often?

For what condition(s)?

21) Are you currently in Physical Therapy? *

Yes

If yes, what condition(s)?

22) Are you currently a recreational or competitive athlete? *

Yes

Sports you play or would like to play:

23) What is your occupation? *

24) Describe your physical activity over the last 3 months on average *

Describe any past or current musculoskeletal conditions you have incurred (muscle pulls, sprains, strains, fractures, surgeries, pain or general tightness and/or discomfort.)

Head/ Neck:

Upper Back:

Shoulder/Colar Bone:

Lower Back:

Arm/Elbow/Wrist:

Hip/Pelvis:

Thigh/Knee:

Lower Leg/Ankle:

Are there any medical conditions not covered? If yes please explain:

List 3 goals you want to accomplish here at IQFIT, in order of importance; and why each one is important to you:

1) *

Why: *

2) *

Why *

3) *

Why: *

When you accomplish the above goals, describe how will this improve your quality of life? *

If you fail to take action on the above goals, describe how this will impact your quality of life *

What has been your biggest issue holding you back from achieving your above goals? *

Please describe why this is the right time in your life to seek professional help - why now?

Did you use Google to find us? *

Yes

If you used Google what did you search for?

Were you referred by a practitioner? *

Yes

If referred, what is their name?

Did you hear from us through another source? *

Yes

What was the other source?

To reach any goal, at least 2 sessions per week are required. Are you financially prepared to invest at least $35 per session for professional custom coaching - a.k.a personal training? *

Yes

Is morning, mid-day or evening best for a 60 to 90 minute 1 on 1 complimentary consultation?

Morning

Mid-day

Evening

Are you a high school student or under 18 years old? *

Yes

If yes, provide the name and number of the parent or guardian who will accompany you at your Fitness Evaluation

WAIVER & RELEASE FORM

Because physical exercise can be strenuous and subject to risk of serious injuries, IQFit urges you to obtain physical examination from a doctor before using any exercise equipment or participating in any exercise activity. You (each member, guest and all participating family members) agree that if you engage in any physical exercise or activity, or use any club amenity on the premises or off the premises, including any IQFit sponsored event, you do so entirely at your own risk. Any recommendation for changes in diet, including the use of food supplements, weight reduction and/or body building enhancement products are entirely your responsibility and you should consult a physician prior to undergoing any dietary or food supplement changes. You agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness or death. We are also not responsible for any loss of your personal property. This waiver and release of liability includes, without limitation, all injuries which may occur, regardless of negligence, as a result of; (a) your use of all amenities and equipment in the facility and your participation in any activity, class, or program, personal training or instruction; (b) the sudden and unforeseen malfunctioning of any equipment; (c) our instruction, training, supervision, or dietary recommendations; and (d) your slipping and/or falling while in the club or on IQFit premises including adjacent side-walks and parking areas. With the signature below you grant IQFit and its licensees permission to publish your personal profile and/or testimonial and any accompanying photographs in any media now known or hereafter invented (including online interactive products) without further cost or any time or geographic limitation. You also authorize IQFit and its licensees to use your name, personal profile and/or testimonial, photo and/or right to use your likeness in/for advertisements and publicity efforts for IQFit, including promotions on the Internet. At the same time, you recognize that IQFit is under no obligation to use or distribute this material. You acknowledge that you have carefully read this “waiver & release” and fully understand that it is a release of liability. you expressly agree to release and discharge IQFit and all affiliates, employees, agents, representatives, successors or assigns from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring legal action against IQFit for negligence, personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of IQFit, its agents and employees. If any portion of this release from liability is deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release shall remain in effect and the offending provision(S) severed here from.

Full Name *

By typing your name and hitting the submit button, you agree that all information you provided is accurate. You also agree to the waiver and release form.

Today's Date: *

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