Soma Mark

Contact Mark Marcello--To Schedule Your Three 45 Minute Training Sessions!

Three 45 Minute Training Sessions price $150.00.  You will be emailed with the necessary forms and instructions after ordering.

Name

Address

CityState

Zip Code  USA Other Canada

Email Address

Fitness Goals - Rank your goals in undertaking exercise:  What do you want exercise to do for you?  Use the following scale 1 -10, 1 being extremely important and 10 not at all important,  to rate each goal separately. 

1 2 3 4 5 6 7 8 9 10   Improve cardiovascular fitness

  1 2 3 4 5 6 7 8 9 10 Body-fat weight loss

1 2 3 4 5 6 7 8 9 10   Reshape or tone my body

1 2 3 4 5 6 7 8 9 10   Improve performance for a specific sport 

What sport?

1 2 3 4 5 6 7 8 9 10   Improve moods and ability to cope with stress

1 2 3 4 5 6 7 8 9 10 Improve flexibility

1 2 3 4 5 6 7 8 9 10   Increase strength

1 2 3 4 5 6 7 8 9 10 Increase energy level

  1 2 3 4 5 6 7 8 9 10 Improve overall health

1 2 3 4 5 6 7 8 9 10   Feel better

1 2 3 4 5 6 7 8 9 10 Enjoyment

1 2 3 4 5 6 7 8 9 10   Stay motivated to exercise

1 2 3 4 5 6 7 8 9 10 Exercise more efficiently

1 2 3 4 5 6 7 8 9 10 Exercise while I travel

1 2 3 4 5 6 7 8 9 10   Nutrition

1 2 3 4 5 6 7 8 9 10   Gym design

  Other:                 

What is the best time for us to talk?  (Click all that apply)

ASAP                    This week                    Next week

Mornings                Afternoons                    Evenings

Anytime                      Date

Phone Number:

Heath Screening:

Physician's Name:

Physician's Phone#

Person to contact in case of emergency, include name, relationship and Phone #:

Are you taking any medications of drugs?  What?

Does your physician know you are participating in this exercise program?

Describe your exercise program now.

Do you now, or have you had in the past:

1. History of heart problems, chest pain or stroke? yes no
2. Increased blood pressure? yes no
3. Any chronic illness or condition? no yes
4. Difficulty with physical exercise? no yes
5. Advise from physician not to exercise? no yes
6. Recent surgery (last 12 months)? no yes
7. Pregnancy (now or within last 3 months)? no yes
8. History of breathing or lung problems? no yes
9. Muscle, joint, or back disorder, or any previous injury still affecting you? no yes
10. Diabetes or thyroid condition? no yes
11. Cigarette smoking habit? no yes
12. Obesity (more than 20% over ideal body weight)? no yes
13. Increased blood cholesterol? no yes
14. History of heart problems in immediate family? no yes
15. Hernia, or any condition that may be aggravated by lifting weights? no yes

Please explain any yes answers:

Comment or Questions:

INFORMED CONSENT

By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive physical exercise.  In signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results in including but not limited to abnormal blood pressure, fainting, heart attack or death.  By signing this document, I assume all risk for my health and well being and hold harmless of any responsibility, the instructor, facility or any persons involved with this program and testing procedures.

Print name as Signature: 

Date: 

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