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Dr. Tony Tanzi, PT, DPT, CSCS
Dr. Kyle Ioos, PT, DPT
Dr. Matthew Aquilino, PT, DPT
Jeffrey Mansfield, PT, MSPT
Dr. Adelaide Ronk, DPT
Alana Keith, PTA
Physical Therapy
Back Pain
Knee Pain
Shoulder Pain
Ankle Pain
Sports Rehabilitation
Join Our Team!
Blog
5 Minute Friday
Contact Us
Home
About Us
Meet The Team
>
Dr. Tony Tanzi, PT, DPT, CSCS
Dr. Kyle Ioos, PT, DPT
Dr. Matthew Aquilino, PT, DPT
Jeffrey Mansfield, PT, MSPT
Dr. Adelaide Ronk, DPT
Alana Keith, PTA
Physical Therapy
Back Pain
Knee Pain
Shoulder Pain
Ankle Pain
Sports Rehabilitation
Join Our Team!
Blog
5 Minute Friday
Contact Us
Please answer all questions accurately and honestly to allow us to fully determine your individual needs.
Fitness Questionnaire
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Indicates required field
First Name
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Last Name
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Do you have high cholesterol?
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Yes
No
Has your doctor ever said that you have heart trouble?
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Yes
No
Are you over the age of 65 and not accustomed to exercise?
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Yes
No
Has your doctor ever told you that you have a joint problem that may be exacerbated by physical activity?
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Yes
No
Is there any reason, not mentioned thus far, that would not allow you to participate in a physical fitness program?
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Yes
No
If yes, please explain
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Do you ever feel weak, fatigued, or sluggish?
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Yes
No
How many meals do you eat each day?
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Do you know how many calories you eat in a day?
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Yes
No
Do you eat breakfast?
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Yes
No
Do you crave sugary foods?
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Yes
No
Are you taking supplements? (vitamins, protein shakes, etc.)
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Yes
No
Do you need several cups of coffee to keep you going throughout the day?
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Yes
No
Do you often expierence digestive difficulties?
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Yes
No
Proper nutrition can increase the body's ability to enhance physical and mental performance by up to 80%. Do you feel that a properly structured exercise and nutrition program would benefit you?
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Yes
No
How long have you been exercising?
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Have you reached and maintained your goals?
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Yes
No
Are you happy with the way you look and your health?
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Yes
No
On a scale of 1 to 10 how serious are you about achieving your goals? (10 is most serious)
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1
2
3
4
5
6
7
8
9
10
Please list your desired fitness goals:
Desired weight (lose x pounds)
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Desired waist size (drop x sizes)
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Desired dress or pant size (go down x sizes)
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I plan to exercise (blank) times a week
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Other: (Look good for summer vacation, be able to keep up with my son etc)
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How did you hear about the 21 Day Back To School Transformation? (Facebook) (ad) (If you heard from a friend please write their name!
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BUYER ACKNOWLEDGMENT AND ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF EMPIRE PERFORMANCE PT. BUYER ACKNOWLEDGES THESE PHYSICAL ACTIVITIES INVOLVES THE INHERENT RISK OF PHYSICAL INJURIES OR OTHER DAMAGES, INCLUDING, BUT NOT LIMITED TO, HEART ATTACKS, MUSCLE STRAINS, PULLS OR TEARS, BROKEN BONES, SHIN SPLINTS, HEART PROSTRATION, KNEE/LOWER BACK/FOOT INJURIES AND ANY OTHER ILLNESS, SORENESS, OR INJURY HOWEVER CAUSED, OCCURRING DURING OR AFTER BUYER’S PARTICIPATION IN THE PHYSICAL ACTIVITIES. BUYER FURTHER ACKNOWLEDGES THAT SUCH RISKS INCLUDE, BUT ARE NOT LIMITED TO, INJURIES CAUSED BY THE NEGLIGENCE OF AN INSTRUCTOR OR OTHER PERSON, DEFECTIVE OR IMPROPERLY USED EQUIPMENT, OVER-EXERTION OF A BUYER, SLIP AND FALL BY BUYER, OR AN UNKNOWN HEALTH PROBLEM OF BUYER. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY INVOLVED WITH PARTICIPATION IN THE PHYSICAL ACTIVITIES, BUYER AFFIRMS THAT BUYER IS IN GOOD PHYSICAL CONDITION AND DOES NOT SUFFER FROM ANY DISABILITY THAT WOULD PREVENT OR LIMIT PARTICIPATION IN THE PHYSICAL ACTIVITIES. BUYER ACKNOWLEDGES PARTICIPATION WILL BE PHYSICALLY AND MENTALLY CHALLENGING, AND BUYER AGREES THAT IT IS THE RESPONSIBILITY OF BUYER TO SEEK COMPETENT MEDICAL OR OTHER PROFESSIONAL ADVICE, REGARDING ANY CONCERNS OR QUESTIONS INVOLVED WITH THE ABILITY OF BUYER TO TAKE PART IN EMPIRE PERFORMANCE PT PHYSICAL ACTIVITIES. BY SIGNING THIS AGREEMENT, BUYER ASSERTS THAT HE OR SHE IS CAPABLE OF PARTICIPATING IN THE PHYSICAL ACTIVITIES. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY FOR NOT EXCEEDING HIS OR HER PHYSICAL LIMITS.
Assumption Of Risk and Liability Release Form
I have read the above assumption of risk and release from liability form.
*
Yes
Initials
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Submit
