Assessment Form Please read consent waiver below before filling out the form. CONSENT WAIVER Name * First Name Last Name Please Read Below I, (THE ABOVE NAME) HERBY VOLUNTARILY GIVE CONSENT TO ENGAGE IN A FITNESS TEST AND A PHYSICAL ACTIVITY PROGRAM. I UNDERSTAND THAT THE CARDIOVASCULAR FITNESS TEST WILL INVOLVE PROGRESSIVE STAGES OF INCREASED EFFORT AND THAT AT ANY TIME I MAY TERMINATE THE TEST AND ACTIVITY FOR ANY REASON. I UNDERSTAND THAT DURING SOME TESTS I MAY BE ENCOURAGED TO WORK AT MAXIMAL EFFORT AND THAT AT ANY TIME I MAY TERMINATE THE TEST OR ACTIVITY FOR ANY REASON. I UNDERSTAND THAT THERE ARE CERTAIN CHANGES THAT MAY OCCUR DURING THE EXERCISE TEST. THEY INCLUDE ABNORMAL BLOOD PRESSURE, FAINTING, DISORDERS OF HEART BEAT AND VERY RARE INSTANCES OF A HEART ATTACK. I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO MINIMIZE PROBLEMS PRELIMINARY EXAMINATION AND OBSERVATION DURING THE TESTING. I UNDERSTAND THAT I AM RESPONSIBLE FOR MONITORING MY OWN CONDITION THROUGHOUT THE TESTING, AND SHOULD ANY UNUSUAL SYMPTOMS OCCUR I WILL CEASE MY OWN PARTICIPATION AND INFORM THE TEST ADMINISTRATOR OF THE SYMPTOMS. UNUSUAL SYMPTOMS INCLUDE, BUT ARE NOT LIMITED TO: CHEST DISCOMFORT, NAUSEA, DIFFICULTY BREATHING, AND JOINT OR MUSCLE INJURY. ALSO IN CONSIDERATION OF BEING ALLOWED TO PARTICIPATE IN THE FITNESS TESTS, I AGREE TO ASSUME ALL RISKS OF SUCH FITNESS TESTING AND HEREBY RELEASE AND HOLD HARMLESS THE TRAINER WHO PERFORMS THESE TESTS AND THEIR AGENTS AND EMPLOYEES FROM ANY AND ALL HEALTH CLAIMS, SUITS, LOSSES OR CAUSES OF ACTION FOR DAMAGES, FOR INJURY OR DEATH, INCLUDING CLAIMS FOR NEGLIGENCE, ARISING OUT OF RELATED TO MY PARTICIPATION IN THE FITNESS ASSESSMENT OR FITNESS PROGRAM. I HAVE READ THE FOREGOING CAREFULLY AND I UNDERSTAND MY CONSENT. I HAVE BEEN ADVISED TO CONSULT MY PHYSICIAN BEFORE STARTING ANY PHYSICAL ACTIVITY PROGRAM. ANY QUESTIONS WHICH MAY HAVE OCCURRED TO ME CONCERNING THE INFORMED CONSENT HAVE BEEN ANSWERED TO MY SATISFACTION. Date * Please fill out today's date MM DD YYYY Thank you! The following is required for those who have paid for personal training only before your initial session.New client assessment form.Consult your physician before starting any physical activity program Name * First Name Last Name Email * Gender * Male Female Age * Numeric Value only Height 4'0" 4'1" 4'2" 4'3" 4'4" 4'5" 4'6" 4'7" 4'8" 4'9" 4'10" 4'11" 4'12" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 5'12" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11" 6'12" 7'0" 7'1" 7'2" 7'3" 7'4" 7'5" 7'6" 7'7" 7'8" 7'9" 7'10" 7'11" 7'12" 8'0" Weight * (Number value only) (Fill in your last known weight) Birthday You will be added to the birthday list MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile Home Work Client's Hopes & Dreams Comprehensive PAR-Q Has your doctor ever told you that you have heart trouble? * Yes No Do you currently have diabetes? * Yes No Are you male 40 years or older, or female 50 years or older? * Yes No Have you had pains in your heart or chest? * Yes No Do you at times feel faint or have spells of severe dizziness? * Yes No Do you have asthma, emphysema or bronchitis? * Yes No Do you currently have thyroid problems? * Yes No Have you had any of the following: Shortness of breath especially upon exertion; heart palpitations; leg cramps during walking; or persistent swelling around the ankles? * Yes No Has a doctor ever told you about bone or joint problems such as arthritis that has been aggravated by exercise or might be made worse with exercise? (required) Yes * Yes No Are you pregnant? * Yes No Has a doctor ever told you that your blood pressure was too high? * Yes No Have your parents, brothers, or sisters suffered from heart disease before the age of 55? * Yes No Are you currently a cigarette smoker or have you smoked within the last 6 months? * Yes No Has your doctor told you that your cholesterol level is too high? * Yes No FAMILY HISTORY Has either of your parents or siblings experienced any of the following conditions? Select All That Apply Heart Attack Blood Lipid Disorder High Blood Pressure Congenital Heart Disease Heart Operation Diabetes MEDICAL HISTORY Have you had, or do you have any of the following conditions? Select All That Apply Rheumatic Fever Fainting Or Dizziness Short-Term Numbness on One Side, Arm or Chest Palpitations or Tachycardia Back or Knee Injury Chest Pains Low Blood Pressure Heart Disease Asthma High Blood Pressure Shortness of Breath Temporary Loss of Visual Acuity or speech Osteoporosis Lung Disease Fatigue Hypoglycemia Arthritis Breathing Difficulties Seizures Heart Murmur Intermittent Claudication (Leg Cramping) Recent Operation Diabetes Edema Hyperglycemia High Cholesterol Thyroid Condition Blood Pressure Fill in your last known reading for your blood pressure (If unknown, skip this step) Resting Heart Rate Take your pulse first thing in the a.m to get an accurate reading on your resting heart rate. (If unknown, skip this step) Depression Scale Where do you rate yourself? Select 1 I typically do not feel sad I feel sad less than half the time I feel sad more than half the time I feel sad nearly all the time Stress Levels On a scale of 1 (Low) to 10 (High) Please rate your current stress level 1 2 3 4 5 6 7 8 9 10 Other conditions & Comments YOUR GOALS & FITNESS INTERESTS What do you want to achieve with personal training? Select all that apply: Weight Loss Flexibility Reduce Body Fat Improve Physical Strength Improve Cardiovascular Health Stop Smoking Improve Posture Improve Eating Habits Reduce Prescription Drug Use Reduce Stress Overall Wellness Rehabilitation Healthier Heart Improve Mobility/Stability Quit Drinking Streamline Workout Strengthen Bones Gain Muscle Sport Specific Training Increased Energy Motivation Reduce Risk of Disease Improve Balance & Coordination Improve Sleep Quality Exercise More Regularly Lower Cholesterol Tone & Firm Other Goals & Comments LIMITING FACTORS Do you have any specific current or former injuries, limiting conditions, previous surgeries or chronic/regular pain in any of the following areas that may affect your ability to exercise? Select All That Apply: Neck Lower Back Hands Shoulders Hips Feet Arms Knee Please provide details or other information Please list any medications you currently use which might affect your heart rate, blood pressure or affect your ability to exercise. EXERCISE AND PERSONAL HISTORY Please fill in the following accordingly Are you currently exercising on a regular basis? Yes No Do you strength train? Yes No How many times per week do you exercise on a regular basis? How many times per week do you strength train? How many times per week do you cardiovascular exercise? Which type of cardio do you enjoy the most? What type of exercise routine has worked for you in the past? Are there any specific fitness activities you dislike? Have you ever worked with a personal trainer? It doesn't have to be recent, but any time in the past also counts. Yes No If you answered yes; Please describe your experience with your previous personal trainer How would you describe your current eating habits? Very Good Needs Improvement Pretty Good Poor Just OK FOOD & SPENDING Weekly Grocery spending? How much do you spend on groceries? (Numeric value only) $ How often do you shop for groceries? Weekly Restaurant Spending? How much do you spend eating out? (Numeric value only) $ How often do you eat out? Monthly Supplement Spending? How much do you spend on supplements? (Numeric value only) $ Do you frequently skip meals? Food Allergies? Please describe any dramatic weight gain or loss. Do you often feel stressed? Yes No Sometimes Do you take a multivitamin? Yes No How many hours of sleep do you get per night? How many alcoholic beverages do you consume per week? Numeric Value Only How many cigarettes do you smoke per day? Numeric Value Only How would you describe your energy level? Very High. Generally energetic and efficient Average. I experience lack of physical energy several days each week Poor. Continual physical exhaustion is affecting my quality of life How often have you used antibiotics over the last 12 months? Numeric Value Only PERSONAL LIFESTYLE SUMMARY What is your occupational life like? How do you spend the majority of the day? Typically how active are you most days? Name some of your daily activities. Are you very active during your personal time or in your home life? What sports exercise or physical activities do you enjoy the most? Do you have any issues or considerations of which you want to inform your trainer? HOW DO THESE ELEMENTS OF YOUR LIFE IMPACT YOUR GOALS? (Positive Or Negative) Environment Home Positive Negative Environment Work Positive Negative People Family Positive Negative People Friends Positive Negative Do you have solid support for your goals and desires? Are there family members or friends who can support your effort to improve your health? What has contributed to your fitness level becoming what it is today? What factors have limited your success thus far? Please describe any health or nutrition supplements you consume regularly. In one year I would like to accomplish.... Thank you! Consult your physician before starting any physical activity program Personal Training Contract
