INFORMED CONSENT AND RELEASE OF LIABILITY FOR PERSONAL TRAINING

Informed Consent: I (the undersigned client) wish to participate in an exercise program with Michael Thompson as my personal trainer (the “Personal Trainer”). I understand that there are inherent risks in participating in any exercise program which include injury and even death, and no personal trainer can guarantee that I will not be harmed or injured. Specific risks may include, but are not limited to, death, serious neck and spinal injuries resulting in complete or partial paralysis, heart attack or stroke, concussions, joint or back injuries, broken bones, muscle or ligament tears, and muscle strains and sprains. I acknowledge that I am voluntarily participating in these activities with knowledge of the dangers involved. Assumption of Risk: I hereby agree to fully assume all risks of injury or death carried with any activities connected with my exercise program and any related activities. I knowingly and voluntarily release, waive, discharge, and hold-harmless from any liability the Personal Trainer and the facilities we utilize from any and all claims for personal injury or otherwise, both present and future, that are a direct or indirect result of any intentional, unintentional, or negligent act. Client Responsibilities: I know it is advised that before beginning any exercise program I should consult my doctor and follow his or her instructions or precautions. I hereby acknowledge that I have either had a physical examination and been given my physician’s permission to participate in this exercise program or that I have decided to participate in such activity without the approval of my physician and hereby assume all responsibility of any nature and kind whatsoever for my participation in personal training activities. If there is ever any change in my physical or mental condition which might in any way affect my ability to safely participate in the exercise program, I agree to notify my Personal Trainer immediately. Waiver of Liability: I agree that neither the Personal Trainer nor the facilities we utilize shall be liable or responsible for any injuries or conditions resulting from my participation in the personal training program or any related activities. I expressly release the Personal Trainer and the facilities we utilize, and their principles, agents, assigns, and advisors, from all claims, actions, and judgments which I or my heirs, executors, administrators, or assigns may have or claim to have, and for all injuries, damage, or other conditions which may occur in connection with my participation in the personal training program. This release shall be binding upon my heirs, executors, administrators, and assigns. Acknowledgment of Understanding: I have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance. I understand that I am giving up substantial rights, including the right to sue. I intend my signature to be a complete and unconditional release of all liability that is a direct or indirect result of any intentional, unintentional, or negligent act. Severability and Amendment: The terms and provisions of this Agreement are to be severable. If any one or more of its terms and provisions is found by any court of competent jurisdiction to be for any reason invalid or unenforceable, such finding is not to affect the enforceability of the rest of the Agreement. This Agreement may not be amended, by course of conduct or otherwise. By submitting my e-signature below, I certify that I have read and fully understand this Agreement and am entering this Agreement voluntarily and of my own judgment.

Name

First Name

Last Name

Date

YYYY

Physical Activity Readiness Questionnaire (PAR-Q)

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO.

1. Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor?

YES

2. Do you feel pain in your chest when you do physical activity?

YES

3. In the past month, have you had chest pain when you were not doing physical activity?

YES

4. Do you lose your balance because of dizziness or do you ever lose consciousness?

YES

5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?

YES

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

YES

7. Do you know of ANY OTHER REASON why you should not do physical activity?

YES

If you answered YES to one or more questions:

Talk to your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want – as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. Find out which community programs are safe and helpful for you.

If you answered NO to all questions Delay becoming much more active:

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can: -Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go. -Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. If you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better. If you are or may be pregnant – talk to your doctor before you start becoming more active. Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

E-SIGNATURE

NOTE: If the PAR-Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section may be used for legal or administrative purposes. I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.

Name

First Name

Last Name

Date

YYYY

NOTE:

This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.

Initial Assessment & Triage Questionnaire

Name

First Name

Last Name

Mobile Phone

Home Phone

Staying in touch

How do you prefer me to contact you?

Phone

Skype or other video chat

Text

Other

Specify other, if necessary

Emergency Contact Name

First Name

Last Name

Emergency Contact Number

Other goals:

What do you want to change?

How, specifically, would you like your habits, your health, your eating, and / or your body to be different?

Out of all of the changes you’d like to make, which ones feel most important / urgent?

List your top three

Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body?

If so, what?

Which of those things worked well for you, and why?

(Even just a little bit, and even if you might not be doing them right now.)

EATING HABITS

Please answer the questions as honestly as you can. There are no right or wrong answers.

General Eating Paterns

As best as you can remember right now, tell me generally about an average day of eating and drinking. This doesn’t have to be perfect; just capture your usual patterns.

Right now, are you following any particular diet or style of eating?

(e.g., vegetarian / vegan, Paleo, kosher / halal, low-carb)

Yes

If yes, what? And for how long have you followed this way of eating?

What are some of the foods or meals you like MOST?

What are some of the foods or meals you DON’T like?

How consistent would you say you are with your eating habits?

1 being "All over the place", and 10 being "Perfectly consistent, all the time."

If you’re less consistent than you’d like to be, what seems to get in the way or knock you off track?

Do you have any known / diagnosed food allergies or intolerances?

If yes, what are those?

Do you have any suspected or possible food allergies or intolerances?

If yes, what are those?

How often do you have a bowel movement?

More than 3 times daily

2-3 times daily

1-2 times daily

Once every 2-3 days

A few times a week

Weekly or less

Do you have any digestive system complaints right now?

If yes, what are those?

On a scale of 1-10, how would you describe your normal appetite / hunger?

1 being "Never hungry" and 10 being "Always starving/ravenous"

Do you feel like you have trouble controlling your appetite / hunger?

Do you normally struggle with food cravings?

If yes or sometimes, what do you normally crave?

What do you normally do when you have cravings?

Have you ever noticed any connection between your emotions and your eating habits?

If yes, what happens? (e.g., When I’m feeling sad I use food to comfort myself; when I’m happy I notice I have fewer cravings)

Have you ever noticed any connection between stress and your eating habits?

If yes, what happens? (e.g., When I’m stressed I eat more / less)

How often do you think about food and eating (or avoiding eating)?

If you think about food and eating more than sometimes, what in particular do you think about?

How often do you eat to the point of being full or stuffed?

If you feel you’ve eaten too much, what do you do afterwards?

Check all that apply.

Try to eat less at subsequent meals

Try to get back in control of things

Keep eating...what the heck, already blown it

Skip the following meal(s)

Purge by vomiting or laxatives

Try to exercise to burn it off

Forget about it and go back to normal eating

Feel bad

Other:

How often do you skip meals or purposely go a long time without eating?

How often do you normally make meals at home?

How often do you normally eat meals in restaurants / cafeterias?

How often do you shop for food?

On a scale of 1 to 10, how would you rank your food preparation and cooking skills right now?

1 being "terrible, nonexistent" 10 being "expert chef"

Do you like cooking?

If no, what do you NOT like? If yes or sometimes, what do you enjoy about it?

Thinking about all that you have written down here, what do you think you might like to start working on or addressing first?

IDENTITY, VALUES, AND GOALS

Who are you? What matters to you? And how do your goals flow from that?

"I'm the type of person who..."

Continue this phrase with things that are true of you. Try to list at least 3.

"And it's important to me that..."

Continue the sentence from the previous entry, for all of your statements

"So I'd feel good about accomplishing..."

Use the previous statements to complete this phrase.

CHANGE CAPACITY ASSESSMENT

How can I change successfully? Change isn’t just about how much you want to change. It’s about the change-making skills that you have, or are willing to learn and practice. This assessment can help me know what next steps will most help you change and reach your goals. Please be as honest as possible. There is no judgement here. These are just data. Having accurate information allows us to work together to help you reach your goals. Answer the following questions based on your current circumstances, using the scale of 1 being "Not True at all" and 10 being "Completely True”

I don’t mind deviating from my routines and plans if I have to.

Trying my best at work and in my personal life makes a difference.

I strive to be a little better through effort and practice.

I recognize that challenges and failures are an opportunity for growth.

When things don’t go as planned, I seek feedback from others to help me succeed.

I am confident that I can perform effectively on many different tasks.

In general, I think that I can accomplish outcomes that are important to me.

When I am confronted with a problem, I can usually find several solutions.

I can express my emotions directly, maturely, and honestly.

When I’m faced with a stressful situation, I’m able to think about it in a way that helps me stay calm.

I can manage my stress or emotions without relying on particular substances or behaviors to cope (e.g., food and eating, alcohol, drugs, shopping, scrolling social media, etc.)

I know who I am, what I want, and what I don’t want.

The way I am living reflects my deeper values.

I connect my goals, and my actions towards those goals, with a deeper purpose.

I can count on others when I need help.

My surrounding environment promotes positive thoughts and actions around change.

I have a close network of people with common interests, values, and goals.

ESSENTIAL SKILLS ASSESSMENT

This assessment can show us how consistently and well you do some of the essential nutrition and lifestyle practices. There is no judgement here. These are just data. Having accurate information allows us to work together to best help you reach your goals. Use a scale of 1 being "Not true at all" and 10 being "Completely true."

I include 1-2 palm-sized portions of protein at most meals.

I include 1-2 fist-sized portions of vegetables at most meals.

I eat an appropriate amount of carbs for my needs, preferences, and goals.

(E.g., I fuel and recover from workouts well, my sleep is solid, I enjoy my food without feeling overstuffed, etc.)

I eat an appropriate amount of fats for my needs, preferences, and goals.

(E.g., healthy skin and hair, healthy hormones, I enjoy my food without feeling overstuffed, blood lipids at healthy levels, etc.)

I drink enough fluids to stay well hydrated.

I choose mostly minimally-processed, lean sources of protein.

(E.g., poultry, fish, shellfish, lean beef or pork, tofu, tempeh, eggs, Greek yogurt, cottage cheese, etc.)

I eat a variety of fresh, differently colored vegetables (and fruits). Green, white, yellow, orange, red, blue, purple - I eat them all!

I eat mostly slow-digesting, high-fiber, nutrient-rich “smart carbohydrates”.

(E.g., fruits, potatoes, sweet potatoes, whole grains, beans/ legumes, other starchy tubers such as yams or yuca, etc.)

I eat mostly healthy fats.

(E.g., nuts / nut butters, seeds, olive oil, avocados, aged cheese, dark chocolate, etc.)

I drink mostly low-calorie, minimally-processed beverages.

(And most high-calorie beverages are for fueling or recovering from workouts.)

I plan most of my meals. And prepare them ahead of time if needed.

(Or, I have a trusted system such as meal delivery.)

Most of the time, I eat fairly regularly, at consistent intervals. Sometimes, if I’m not hungry, I won’t eat.

I generally ensure my food environment supports my goals.

(E.g., I keep healthy foods in the house or easily available, and keep problematic foods out of the house or out of sight, etc.)

I eat slowly and mindfully, with few distractions. I notice the taste and texture of my food.

I stop eating once I am satisfied (before I am stuffed).

I eat when I am physically hungry. If I indulge, I do so intentionally and without guilt.

Around bedtime I consistently practice behaviors that promote restful sleep, and use a nightly pre-bed ritual to prepare for sleep.

(E.g., turn off electronics 30 minutes before bedtime, avoid caffeine and alcohol near bedtime, dim the lights, etc.)

My sleep environment helps me get a good night’s rest.

(E.g., dark, quiet, cool, uncluttered, comfortable sleeping space, etc.)

I plan my bedtimes to try to get plenty of high-quality sleep (7-9 hours).

I am able to wake without hitting snooze, and I have a morning routine that supports wakefulness.

(E.g., expose myself to light, do some light movement, have a reasonable amount of caffeine, etc.)

I make time for healthy habits by planning ahead.

I prioritize what is most important, and set boundaries on my time, energy, and attention.

(E.g., I choose a time to finish work, turn off electronic devices to focus on priorities, prioritize supportive over toxic relationships, etc.)

I keep my home and work spaces relatively organized, and intentionally set it up to support my goals and minimize tension or stress.

(Including having some “me space”.)

I purposefully relax, have fun, and de-stress.

I drink alcohol moderately, or don’t drink at all.

(E.g., <14 drinks per week for a man, <7 drinks per week for a woman.)

I exercise or do some regular movement.

(E.g., walking, running, cycling, group classes, strength training, etc.)

I do different kinds of movements and try to get movement variety.

(E.g., both intense and relaxing, in different environments, diverse types of sports or physical activities, etc.)

I am able to move freely with little or no pain or restrictions.

I express my emotions directly, maturely, and honestly.

I manage my stress or emotions without relying on particular substances or behaviors to cope.

(E.g., excessive: food and eating, alcohol, drugs, shopping, scrolling social media, etc.)

I regularly try to connect with friends, family, or peers.

I strive to be a little better through effort and practice.

I recognize that challenges and failures are an opportunity for growth.

The way I am living reflects my deeper values.

I connect my goals, and my actions towards those goals, with a deeper purpose.

STRESS & RECOVERY

Think about your sleep habits and quality right now.

On average, how many hours per night do you sleep?

4 or fewer hours

5 hours

6 hours

7 hours

8 hours

9 hours

10 or more hours

Do you do shift work?

Yes

What is your typical bedtime?

On a scale of 1-10, with 1 being "horrible" and 10 being "AWESOME!!!", how good is your sleep quality?

What tends to interfere with you getting enough sleep, and / or the quality of your sleep?

What, if anything, tends to help you sleep better / longer?

Do you currently take any medications or natural health products to help yourself sleep?

Yes

If yes, what?

Other stress factors?

Considering all these factors, how would you rank your overall level of stress right now?

1 being "no stress" 10 being "extreme stress"

Considering all these factors, how well would you say you’re coping right now?

1 being "horribly" 10 being "perfectly"

What, if anything, do you do right now to cope and / or recover from stressors?

(Include physical, mental, and emotional recovery.)

How physically energetic and vital do you normally feel on an average day?

1 being "exhausted" 10 being "superstar!"

On an average day, do you have any persistent pain, soreness, stiffness, aching, etc.?

Yes

If yes, how bad is it?

1 being "almost nothing" 10 being "Excruciating/disabling"

How mentally “sharp”, quick, and clear do you normally feel on an average day?

1 being "total brain fog" 10 being "genius"

How happy and cheerful do you normally feel on an average day?

1 being "completely depressed" 10 being "ray of sunshine"

Today, how interested are you in exercise and / or training? How excited to train?

1 being "I'd rather take a nap" 10 being "Let's crush it!"

For women: If you should be having regular periods, are you?

Yes

If no, how long has it been since your last period?

Mindset Promise: "I am willing to participate with an open mind, I am open to change, and I am willing to adopt flexible mindset behaviors. I agree that I am ready to make change and to fully commit to myself and this process." Please type your name below stating you agree to the above statement.

MJT Training CLIENT INTAKE FORM: Mike