Mind, Body, Spirit

Your Name:
Email:
Your Date of Birth (month/day/year in this order please):
Time of Birth (Include AM, PM, or Unknown):
City, State, Country of Birth:
Current WEIGHT:
DESIRED WEIGHT:
BY (DATE):
WOULD YOU DESCRIBE YOURSELF AS ACTIVE OR SEDENTARY:
HAVE YOU BEEN TRAINED IN THE PAST:
IF SO, HAVE YOU BEEN ABLE TO ACHIEVE GOOD RESULTS WITH TRAINING AND DIET IN THE PAST:
IS YOUR JOB or Daily Life PHYSICALLY DEMANDING OR DO YOU SPEND A LOT OF TIME SITTING:
WHERE ARE YOU ON THIS SCALE; LEAN 1 2 3 4 5 6 7 8 9 10 FAT: 
WHAT DO YOU WANT FROM A FITNESS PROGRAM? (LOSE WEIGHT, TONE UP, ETC.):
HOW MUCH TIME CAN YOU DEVOTE TO EXERCISE EACH WEEK (HEALTH EXPERTS RECOMMEND 3-5 HOURS OF EXERCISE PER WEEK FOR OPTIMUM RESULTS) 1 2 3 4 5 HOURS: 
ARE YOU WILLING TO COMMIT TO FOLLOW ALL INSTRUCTIONS TO THE LETTER, ESPECIALLY REGARDING MENU, FOR 8-12 WEEKS IN ORDER TO ACHIEVE YOUR GOALS: 
DID YOU KNOW THAT NUTRITION IS AT LEAST 80% RESPONSIBLE FOR WEIGHT GAIN OR LOSS, EVEN WHEN EXERCISING (BED RIDDEN OPTIFAST PATIENTS ROUTINELY LOSE 100 POUNDS WITHOUT EXERCISING): YES or NO
WHAT SERVICE DO YOU HOPE YOU WOULD RECEIVE FROM A PERSONAL TRAINER: 
WHAT SPECIFIC PHYSICAL NEEDS TO YOU HAVE THAT YOU WOULD LIKE TO ADDRESS, SUCH AS TONE UP, PARTS TO IMPROVE, SUCH AS HIPS, WAIST, STOMACH, ETC: 

YES or  NO 1. HAS YOUR DOCTOR EVER TOLD YOU HAVE HEART TROUBLE?
YES or NO 2. DO YOU FREQUENTLY HAVE PAINS IN YOUR HEART OR CHEST?
YES or NO 3. DO YOU OFTEN FEEL FAINT OR HAVE SPELLS OF DIZZINESS?
YES or NO 4. HAS A DR. EVER SAID YOUR BLOOD PRESSURE WAS TOO HIGH?
YES or NO 5. HAS YOUR DR. EVER TOLD YOU THAT YOU HAVE A JOINT OR BONE PROBLEM, LIKE ARTHRITIS, THAT CAN BE AGGRAVATED BY EXERCISE? 
YES or NO 6. DO YOU HAVE BACK OR NECK PROBLEMS?
YES or NO 7. IS THERE A GOOD PHYSICAL OR PSYCHOLOGICAL REASON NOT MENTIONED HERE WHY YOU SHOULD NOT FOLLOW AN ACTIVITY PROGRAM IF YOU WANTED TO? 
YES or NO 8. ARE YOU OVER AGE 65 AND NOT ACCUSTOMED TO PHYSICAL EXERCISE?

IF YOU ANSWERED YES TO ONE OR MORE QUESTIONS:
IF YOU HAVEN'T RECENTLY DONE SO, CONSULT WITH YOUR DR. BY PHONE OR IN PERSON, BEFORE INCREASING YOUR ACTIVITY LEVEL! TELL HIM WHAT QUESTIONS YOU ANSWERED YES TO ON SURVEY. AFTER MEDICAL EVALUATION, SEEK ADVISE FROM YOUR DR. AS TO YOUR SUITABILITY FOR: UNRESTRICTED PHYSICAL ACTIVITY, PROBABLY ON A GRADUALLY INCREASING BASIS; RESTRICTED OR SUPERVISED ACTIVITY TO SUIT YOUR NEEDS, AT LEAST INITIALLY. IF YOUR DOCTOR IS AWARE OF THE PROBLEM, PUT YOUR INITIALS AND A NOTE NEXT TO THE QUESTION (S) YOU ANSWERED 'YES' TO, EXPLAINING WHY IT IS O.K. TO PROCEED WITH CAUTION.

NO TO ALL QUESTIONS:  IF YOU ANSWERED ACCURATELY, YOU HAVE REASONABLE ASSURANCE OF YOUR PRESENT SUITABILITY FOR: A GRADUATED EXERCISE PROGRAM. IF YOU HAVE A TEMPORARY MINOR ILLNESS, LIKE A COLD, POSTPONE INCREASED ACTIVITY. 

YOU AGREE TO THE TERMS OF THIS RELEASE FORM. TRAINING AND EXERCISE CAN BE A STRENUOUS ACTIVITY. YOU, THE GUEST/CLIENT/MEMBER, ARE AWARE THAT YOU ARE ENGAGING IN PHYSICAL EXERCISE AND THAT THE USE OF ANY EQUIPMENT RECOMMENDED, TRAINING AND INSTRUCTION, COULD CAUSE INJURY TO YOU. YOU ARE VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES AND ASSUME ALL RISKS OF INJURY THAT MIGHT RESULT. YOU AGREE TO WAIVE ANY CLAIMS OR RIGHTS YOU MIGHT OTHERWISE HAVE TO SUE ASTROLOGYMATCH.COM, PAMELA FOTTRELL, OR ANY AGENT, EMPLOYEES OR INSTRUCTORS, FOR INJURY TO YOU AS A RESULT OF THESE ACTIVITIES, ADVICE, SUGGESTIONS, OR INSTRUCTIONS. IT IS ALWAYS ADVISABLE AND RECOMMENDED TO CONSULT YOUR PHYSICIAN BEFORE UNDERTAKING THIS OR ANY EXERCISE PROGRAM.
YOU ALSO AGREE THAT THIS FEE OF $125 IS NON-REFUNDABLE. SHOULD YOU DISCONTINUE THIS PROGRAM, THAT INCLUDES AN EMAILED ASSESSMENT, TRAINING, DIET AND EXERCISE INSTRUCTIONS, AS WELL AS SIX MONTHS OF SUPPORT FOR FREE, VIA EMAIL.  You also understand that myself, Pamela Fottrell, any associates of mine who contact you on my behalf or the behalf of their establishment or AstrologyMatch.com, and is not responsible for any actions you take or assumptions you make as a result of your weight loss evaluation using both your astrological chart as a guide to your weight loss issues and solutions, as well as what is recommended to you to do in order for you to take the weight off and keep it off.  ANSWER YES TO CONTINUE: 
SIGNED (PARTICIPANT): TYPE YOUR NAME HERE YOU AGREE THAT THIS IS AGREEMENT IS BINDING:
DATE:
ONCE YOU CLICK TO SUBMIT TO PAMELA FOTTRELL, IT IS WITNESSED BY PAMELA FOTTRELL.
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