3 CJ's Informed Consent Form

C.J.
s FUNCTIONL FITNESS AND SELF-DEFENSE LLC

INFORMED CONSENT FORM
Informed Consent Form

I, (print name) ___________________________ , give my consent to participate in the
physical fitness evaluation program conducted by C.J.s Functional Fitness and Self
Defense, LLC.
Benefits
Participation in a regular program of physical activity has been shown to produce positive changes in a number of
organ systems. These changes include increased work capacity, improved cardiovascular efficiency, and increased
muscular strength, flexibility, power and endurance.
Risks
I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and the
cardiorespiratory system (dizziness, discomfort in breathing, heart attack). I hereby certify that I know of no
medical problem (except those noted below) that would increase my risk of illness and injury as a result of
participation in a regular exercise program.
Testing And Evaluation Results
I understand that I may undergo initial testing to determine my current physical fitness status. The testing will
consist of completing this health inventory, taking a step test or bicycle ergometer test for cardiovascular fitness,
and being tested for muscular fitness and body composition. I further understand that such screening is intended
to provide C.J.s Functional Fitness and Self Defense, LLC, with essential information used in the
development of individual fitness programs. I understand that my individual results will be made available only to
me. I also understand that the testing is not intended to replace any other medical test or the services of my
physician. I will be provided a copy of all test results. I may share the results with whomever I please, including my
personal physician. By signing this consent form I understand that I am personally responsible for my actions
during my tenure at C.J.s Functional Fitness and Self Defense, LLC and that I waive the
responsibility of this center if I should incur any injury as a result of my negligence.
Contact Information
Telephone:
_____________________________
Email:
_____________________________
Address:
_____________________________
_____________________________
_____________________________
_____________________________
Emergency Contact Information

Name:
_____________________________
Relationship to you: _____________________________

Telephone:
_____________________________
Signed:
_____________________________
Date: ________
Witness :
____________________________
Date: ________
PO box 875. Lawndale, Ca. 90260 (310) 963-7728

www.cjff.org
C.J.s FUNCTIONL FITNESS AND SELF-DEFENSE LLC

Exercise History
Are you currently involved in a regular exercise program? YES NO
If yes, describe it:
Do you frequently compete in competitive sports? YES NO

If yes, which one or ones?
Average number of times per week___

What high school or college athletics did you participate in?
What activities would you prefer in a regular exercise program for yourself?
General Medical and Health

a. How tall are you? (feet & inches) _______________
b. What is your current weight? (lbs.) _______________
c. How old are you? ______________ Date of Birth _____________________
d. How would you describe your blood pressure? (circle one) dont know high normal or low
e. What is your blood pressure now? (leave blank if unknown)
systolic (higher number) _______________
diastolic (lower number) _______________
f. What is your cholesterol level (based on blood test)? _______________
g. What is your HDL cholesterol? (leave g. and h. blank if unknown) _______________

www.cjff.org

Current Health Habits

a. Do you use tobacco products? YES NO
If yes, how much and for how long? _______________
b. How much alcohol do you use per day? _______________
c. How much coffee/caffeine do you use per day? _______________
Exercise & Nutrition Profile

a. Do you have any physical problems or limitations that may affect your ability to exercise?
YES NO
b. Have you ever had a serious back or joint? YES NO (if yes, please describe it)
c. Please use the scale below to indicate how often you do each of the following:
1. Usually/frequently 2. Sometimes 3. Rarely/never (Rate from 1-3)
_____ warm-up
_____ cool-down
_____ stretch
_____ finish your workout with very high intensity (all out effort)
_____ exercise with the proper activity-specific footwear
_____ support structure of shoes deteriorate before undersoles wear out
_____ exercise on hard surfaces
_____ work out includes non-weight bearing activities (swim, cycle)
_____ include strength training as part of your workout
d. Do you use nutritional supplements? YES NO
If yes, what type? _______________________
Frequency of use: _______________________
e. Have you recently made any changes in your eating habits? YES NO
Medical/health history
a. During the past 3 months, approximately now many times have you experienced
any pain, pressure, or discomfort in your chest?
1. 0 (skip to question 3)
2. 1-5
3. 6-25
4. 26+
b. Describe the character of the discomfort (check all that apply)
___ sharp, fleeting, localized pain or catch
___ intensity changes if you take a deep breath or change positions
___ dull pressure, ache, tightness, pain, or burning
www.cjff.org

___
___
___
___
___
radiates or spreads to jaw, arm, neck, shoulder, or back

has awakened you from sleep
predictably brought on by exertion
predictably relieved by rest within 10 minutes
predictably relieved by nitroglycerine within 10 minutes
Circle YES or NO to the following questions:

c. Have you ever had a heart attack? YES NO
(if NO, skip to section General medical and Health)
f. How many heart attacks have you had? ____________
g. At what age was your first heart attack?____________
h. Have you ever had bypass surgery? YES NO
If yes, how long ago was your surgery?____________
i. Have you ever had angioplasty? YES NO
If yes, how long ago was your angioplasty?____________
j. Are you in a cardiac rehabilitation program? YES NO
k. Please list and describe any additional problems with your health we should be aware of
including: heart trouble, pain as a result of exercise, walking, or other physical activity,
rapid heart action of palpitations, diabetes, high blood pressure, sugar in your urine, and
medications.

www.cjff.org

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C.J.

s FUNCTIONL FITNESS AND SELF-DEFENSE LLC

Informed Consent Form

Emergency Contact Information

Relationship to you: _____________________________

PO box 875. Lawndale, Ca. 90260 (310) 963-7728

C.J.s FUNCTIONL FITNESS AND SELF-DEFENSE LLC

Do you frequently compete in competitive sports? YES NO

Average number of times per week___

General Medical and Health

PO box 875. Lawndale, Ca. 90260 (310) 963-7728

C.J.s FUNCTIONL FITNESS AND SELF-DEFENSE LLC

Current Health Habits

Exercise & Nutrition Profile

C.J.s FUNCTIONL FITNESS AND SELF-DEFENSE LLC

radiates or spreads to jaw, arm, neck, shoulder, or back

Circle YES or NO to the following questions:

PO box 875. Lawndale, Ca. 90260 (310) 963-7728

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