Step 2 · A few more questions
In the last 3 months, have you exercised on purpose at least 3 days a week for 30 minutes or more? Yes No
Has a doctor ever told you that you have heart disease, diabetes (type 1 or 2), or kidney disease? Yes No
Do you ever have any of these, at rest or when active? (check any) Pain, pressure or tightness in the chest, neck, jaw or arms Shortness of breath that’s unusual for what you’re doing Dizziness or fainting Trouble breathing when lying down, or waking up short of breath Swollen ankles A racing, pounding or irregular heartbeat Leg pain or cramping when walking that goes away with rest A known heart murmur None of these
Do you take any medicines that affect your heart rate, blood pressure or blood sugar? (list them)
Any surgery, injury, hospital stay, pregnancy or new diagnosis in the last 12 months?
Has a doctor cleared you to exercise? Yes, in writing Yes, verbally Not yet Not needed (all NO above)
If you checked a symptom, or said YES to heart, diabetes or kidney disease, please get your doctor’s written OK before training. If a symptom happens during exercise, stop and tell your coach right away. Call 911 for chest pain that doesn’t go away.
Step 3 · Informed consent and acknowledgment
DRAFT: this consent wording is waiting on review by a South Carolina attorney and our insurer before it is used.
Please read each line. Ask Chad about anything that isn’t clear.
Not medical advice. My coach at Triumphant Transformation is a fitness coach, not a doctor, dietitian or other licensed health care provider, and does not diagnose, treat or give medical advice. This check helps decide where to start and is not a medical exam. *
Doctor clearance. I have been advised to talk with my doctor before starting. If I answered YES to any readiness question, or my coach asks, I will get my doctor’s clearance in writing before training. *
Honest information. My answers are true and complete to the best of my knowledge. I will tell my coach right away about any new health condition, injury, medicine change or pregnancy. *
Risks. I understand exercise has risks, including soreness, strains and sprains, falls, and in rare cases heart problems, serious injury or death. I will stop and tell my coach if I feel chest pain or pressure, dizziness, unusual shortness of breath or sharp pain. *
My choice. Taking part is voluntary. I may stop, skip or change any exercise at any time. *
No guaranteed results. Results vary from person to person and depend on effort, health, sleep, nutrition and more. No specific result is promised. *
Faith content. Scripture and prayer are offered as encouragement. I may say no to any faith element without it affecting my coaching. *
Privacy. My answers are used only to plan and run my coaching. They are not sold, and not shared without my permission unless the law requires it. I can ask for a copy, or ask that they be deleted when coaching ends (except records Triumphant Transformation must keep). *
[Release of liability: to be added after attorney review.]
Age. I am 18 or older, or my parent or legal guardian is also signing below. *
Electronic signature. Typing my name below and sending this form has the same effect as signing it by hand. *
Type your full name to sign *
Date *
Under 18? A parent or legal guardian must also read and sign. Minors train only with a parent or guardian’s written consent.
Parent / guardian full name (if under 18)
Relationship to client
Date
Client signature ______________________________ Date ___/___/______
Parent / guardian signature (if under 18) ______________________ Date ___/___/______
Coach ______________________________ Date ___/___/______
Safety first