Intake & Health Form

01 About You

Full legal name *

Date of birth *

Phone / WhatsApp *

Email *

Emergency contact — name *

Relationship to you *

Emergency contact — phone *

02 Your Goals & Weekly Schedule

This is how your trainer builds your full week — the sessions you do together in person, plus the sessions you do on your own in the coaching app.

Sessions per week with your trainer *

Sessions per week on your own (in the app) *

Training experience *

Preferred days & times for our sessions

Your goals — tick all that apply

Your wishes, in your own words — what result do you want, and by when?

03 Health Screening

Please answer every question honestly. This screening protects you: it tells your trainer what to build into your program and what to avoid. Your trainer is not a medical professional, and this form does not replace medical advice.

1.Has a doctor ever said you have a heart condition, or that you should only exercise under medical supervision?

Yes No

2.Do you feel pain, pressure or discomfort in your chest during physical activity — or in the past month, when not exercising?

Yes No

3.Do you ever lose your balance because of dizziness, or lose consciousness?

Yes No

4.Do you have a bone, joint or soft-tissue problem (back, knee, shoulder, hernia, scoliosis) that could be made worse by exercise?

Yes No

5.Are you currently taking medication for blood pressure or a heart condition?

Yes No

6.Has a doctor ever restricted or limited your physical activity in any way?

Yes No

7.Do you know of any other reason why you should not take part in physical activity?

Yes No

Important: If you answered YES to any question above, your trainer may ask you to get written clearance from your doctor before your first session, and some exercises may be adapted or excluded. This is for your safety.

04 Medical History

Tick anything that applies to you now, or has applied in the past — then add details in the lines below.

Surgeries you have had (operation + year) — including C-section, joint, spine, or any major surgery

Chronic conditions & anything ticked above — details in your own words

Medication you take regularly (name + what for)

Allergies (medication, food, latex, other)

Current pain or injury — where, and how bad (1–10)?

Exercises or movements a doctor told you to avoid

05 Your Health Information — Privacy & Consent

Washington's My Health My Data Act protects your health information. Please read how yours is handled, then sign your consent below. This consent is separate from the waiver on the next page.

What is collected: the health information on this form; your measurements and weight; your training records and check-ins in the coaching app; and progress photos, only if you agree to them in Section 08.

Why: only to screen you for safe exercise, build and adapt your training program, and track your progress.

Who sees it: only your trainer. Your health information is never sold and never shared for marketing. It may be stored in the coaching app and business tools your trainer uses to run your program.

Your rights: you may ask at any time what health information is held about you, ask for it to be corrected, and ask for it to be deleted. You may withdraw this consent at any time in writing — if you do, training may have to pause, because your trainer cannot program safely without this information.

Emergencies: your information may be shared with emergency medical services if you are injured or unwell during a session.

BUILT BY JULIE (AstraGold LLC) — Consumer Health Data Privacy Notice. A full privacy policy is available on request and on our website. This notice is a summary for this form and does not replace it.

Client signature — type your full name *

Date *

Printed name

06 Release of Liability, Waiver of Claims & Assumption of Risks

Please read carefully. By signing this document you give up certain legal rights.

In consideration of being allowed to take part in personal training sessions and related activities (the "Training") with Yuliia Radkovska, doing business as BUILT BY JULIE, and AstraGold LLC (together, the "Trainer"), I agree as follows:

Risks of exercise. I understand that physical exercise and personal training involve physical exertion and carry a risk of injury — for example, muscle strains, sprains or other injuries. I accept this risk as part of taking part in the Training.
Assumption of risk. I have been informed of these risks, I understand them, and I voluntarily choose to take part in the Training. I expressly assume all risks of injury or damage arising from my participation, whether known or unknown.
My health. I confirm that the health information I gave in this form is true and complete. I am physically able to take part in the Training, and I will tell the Trainer before every session about any pain, illness, injury, medication change or change in my health. I will stop exercising and inform the Trainer immediately if I feel chest pain, dizziness, shortness of breath or unusual pain.
Release and waiver. I hereby release, waive and discharge the Trainer, and its owners, employees and contractors (the "Released Parties"), from any and all liability, claims, demands and causes of action arising out of or related to any loss, damage or injury that may be sustained by me during or as a result of the Training, including claims arising from the negligence of the Released Parties, to the fullest extent permitted by the laws of the State of Washington.
What is NOT released. This release does not apply to gross negligence, recklessness, or intentional misconduct.
Covenant not to sue; indemnity. I agree not to sue the Released Parties for any claim released above. I agree to indemnify and hold harmless the Released Parties from any loss or expense (including reasonable attorneys' fees) arising from my breach of this document or claims brought by my family or representatives in connection with my participation.
Who is bound. This document binds me and my heirs, executors, administrators, personal representatives and assigns, and is intended to be as broad and inclusive as permitted by Washington law. If any part of it is held invalid, the remaining parts continue in full effect.
Emergencies. In an emergency I authorize the Trainer to administer basic first aid (including CPR/AED if certified) and to call emergency services (911). I understand I am responsible for any resulting medical costs.
Governing law. This document is governed by the laws of the State of Washington. I confirm I am 18 years of age or older (if not, my parent or legal guardian must also sign below). No oral statements or promises have been made to me in connection with this document.

I HAVE READ THIS RELEASE OF LIABILITY, WAIVER OF CLAIMS AND ASSUMPTION OF RISKS, I FULLY UNDERSTAND IT, AND I SIGN IT FREELY AND VOLUNTARILY.

Client signature — type your full name (sign directly below the waiver text) *

Date *

Printed name *

Parent / guardian signature (if client is under 18)

07 Your Acknowledgment & Signature

By signing below, you confirm each of the following:

Client signature — type your full name *

Date *

Printed name

08 Photos & Videos (Optional)

Your trainer creates fitness content. This consent is optional and completely separate — saying no changes nothing about your training.

Initials

Date

01 About You

02 Your Goals & Weekly Schedule

03 Health Screening

04 Medical History

05 Your Health Information — Privacy & Consent

06 Release of Liability, Waiver of Claims & Assumption of Risks

07 Your Acknowledgment & Signature

08 Photos & Videos (Optional)

Thank you — your form is in.

09 What Happens Next