client information and waiver

Welcome! Please answer the questions below and sign the waiver.

Part 1: Client Info

Emergency Contact Name

Emergency Contact Phone

Part 2: Medical Questions

Do you suffer from any of the following conditions? Please check all that apply.

Other existing conditions (if not selected above)

Please explain any conditions you marked or described above.

Please list and explain any medical conditions, including surgery, for which a physician has ever recommended restrictions on activity.

Do you have Osteopenia or Osteoporosis?

What parts of your body are impacted?

Are you taking any supplements or medication for this?

Please list any medications or supplements that you take regularly and the reason for taking them.

Part 3: Fitness and Lifestyle Questions

What are you fitness goals (check all that apply)?

Other fitness goals (if not selected above)

What is your current occupation?

Does your occupation require extended periods of sitting?

Does your occupation require extended periods of repetitive movement? If yes, please explain.

Does your occupation require you to wear shoes with a heel?

Do you partake in any recreational activities (golf, tennis, skiing…) If yes, please explain.

What are your hobbies and how much time do you spend with them? Include things such as gardening, exploring the Internet, TV, reading…

Do you exercise regularly?

On a scale of 1-10 Rate your overall activity level

On a scale of 1-10 Rate your ability to perform cardio exercises

On a scale of 1-10 Rate your experience with exercise

What have been obstacles to your past fitness success?

Approximately How many hours per day do you spend sitting?

Approximately How many hours per day do you spend on a phone, computer or tablet?

Approximately How many hours per day do you spend in a car?

Approximately How many hours per day do you spend standing?

Do you regularly lift objects more than 20 lbs as part of your job?

Please tell us about any other repetitive movements in your day of which we should be aware?

When you sit, do you typically cross your legs? If so, which one is typically on top?

What equipment do you have access to?

On which days are you available to work out?

How long would you like your workouts to be on the days listed above?

Would you like a short exercise routine to perform at your desk?

Do you have any existing injuries or conditions that I should be aware of while building your training plan?

Do you smoke tobacco products?

Any other comments about what you would like to see in your training plan?

24 hour cancellation notice is required. If you do not cancel within 24 hours of your session you will be charged for the full price of the session.
I have read the cancelation policy

Health and Fitness Liability Waiver and Informed Consent

I have enrolled in the Functional Fitness Guru (FFG) program offered by Marilyn Moss. I recognize that the program involves strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various activities.

I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in this exercise program. I acknowledge that my enrollment and subsequent participation is purely voluntary and in no way was mandated by FFG or Marilyn Moss. In consideration of my participation in this program, I, hereby release Marilyn Moss, FFG, and its agents, from any claims, demands, and causes of action as a result of my voluntary participation and enrollment.

I fully understand that I may injure myself as a result of my enrollment and subsequent participation in this program including the Assessment and I hereby release FFG and Marilyn Moss , and its agents, from any liability now or in the future for conditions that I may obtain. These conditions may include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat prostration, injuries to knees, injuries to backs, injuries to foot, or any other illness or soreness that I may incur, including death.

By signing below I hereby affirm that I have read and fully understand the above statements.

Photo and Video Permission

I grant permission to the Functional Fitness Guru to interview, photograph and videotape me and use the aforementioned interview or images in promotional material without compensation.

By signing below I hereby affirm that I have read and fully understand the above statement.

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