INITIAL CONSULTATION COMPULSORY SCREENING FORM 1. GENERAL HEALTH AND FITNESS
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1 INITIAL CONSULTATION COMPULSORY SCREENING FORM CLIENT CONTACT DETAILS NAME ADDRESS P.CODE SEX D.O.B CHILDREN CONTACT NUMBER OCCUPATION EMERGENCY CONTACT NUMBER 1. GENERAL HEALTH AND FITNESS 1.1 Have you had a personal trainer before? If so describe the experience (timeframe/attainment of goals etc) 1.2 Are you currently exercising or participating in any sport? If so please describe in detail what you do on a weekly basis 1.3 Do you have any exercise/sport history? If so please describe. 1 P a g e M o n t y P e r s o n a l T r a i n i n g
2 1. GOAL SETTING 2.1 What are your specific health and fitness goals? 2.2 Why do you want to achieve these goals? 2.3 What time frames or important dates need to be considered? 2.4 Describe how this will make you feel when you achieve these results? 3. MEDICAL SCREENING 3.1 Do you have or have you ever had any of the following? 1. Diabetes. Y N 2. High or Low Blood Pressure. Y N 3. Asthma or Respiratory Illness. Y N 4. Heart or Chest Pains. Y N 5. Epilepsy, Y N 6. Fainting or Dizziness. Y N 7. Arthritis. Y N 2 P a g e M o n t y P e r s o n a l T r a i n i n g
3 3. MEDICAL SCREENING CONTINUED 3.2 Do you have anyone in your immediate family who has suffered from any form of cardiovascular disease (CV), heart disease, CV complication, stroke or any other CV issue? Y N 3.3 Any other medical or health related conditions? Y N 3.4 Have you suffered any major injuries, at any stage in your life, to the following? Head Y N Neck Y N Shoulders (L, R or both) Y N Arms (L, R or both) Y N Hands (L, R or both) Y N Spine Y N Ribs Y N Hips Y N Pelvis Y N Upper legs (L, R or both) Y N Lower legs (L, R or both) Y N Ankles (L, R or both) Y N Feet (L, R or both) Y N Have you suffered from any of the following at any stage in your life? Whiplash Y N Dislocated Shoulder Y N Knee Joint injuries Y N Bone Fractures Y N Disc issues (spinal) Y N Sciatica Y N Ankle sprains Y N Severe episode of pneumonia Y N Rotator cuff injuries in your shoulder Y N If you have circled yes to any of the above please provide as much detail as possible, use the reverse of this form if needed. 3.5 Are you aware of any injury that may be aggravated by any form of physical activity? Y N 3.6 Has your doctor ever advised you not to be physically active in any way? Y N 3.7 Are you presently taking any medication that may affect you during exercise? Y N 3 P a g e M o n t y P e r s o n a l T r a i n i n g
4 PERSONAL TRAINING TERMS AND CONDITIONS By investing in Personal Training you are fast tracking your way to results and investing into your health and wellness. However, it does take two to achieve results. Success requires a level of personal commitment from both trainer and client. Working with a personal trainer is not simply an option to transfer the responsibility for your health onto someone else. Personal Training The most important factor in improving your health and achieving results is consistency. Turning up for every session with your trainer, and striving to complete every session planned by your trainer, is just as important as the quality of the workouts you will complete. Personal Training guarantees you will receive quality instruction and professional service. Your Personal Training session is valuable. We ask that you respect this by notifying us of any session changes at least 24 hours prior to your scheduled training time. Please be 10 minutes early for your appointment time, as a timely session will be planned. What if I cannot attend my session? If you provide more than 24 hours notice from the scheduled session you will not incur any payment for that session, however any session changes made within 24 hours will be charged at the full rate. Investment Methods and Conditions Payments must at all times be made in advance. We have the provision to accept cash, cheque and internet banking transfer. With all personal training options we reserve the right to halt training services should any amount be outstanding. Session Requirements Should you have an injury or any change to your health or medical condition you must notify your trainer prior to any further training and a new pre-exercise screening form may need to be filled in. Please bring a towel, water bottle and appropriate clothing to every session. Workers Compensation Policy Workers compensation sessions are 30 minutes in duration (unless otherwise notified). The One on One Terms and Conditions applies to all workers compensation clients. 100% Guarantee As with any professional business we are not happy unless you are. If for some reason you are not completely satisfied with a session please let your trainer know and a full refund will be provided and a secondary session may be scheduled. 4 P a g e M o n t y P e r s o n a l T r a i n i n g
5 CLIENT ACKNOWLEDGEMENT I have volunteered to participate in a program of physical exercise under the direction of my personal trainer. I do here and forever release and discharge and hold harmless my personal trainer, and their respective agents, heirs, assigns, contractors and employees from any legal claims, demands, damages, rights or cases of action, present or future, arising out of or connected with my participation in this or any exercise and nutrition program including any resulting injuries. I recognise that an examination by a physician, or other relevant health specialist should be obtained prior to commencing my exercise program. If I have chosen not to obtain a physician s permission prior to beginning this exercise program with my personal trainer, I hereby agree that I am doing so at my own risk. I understand and accept my personal trainer s 24 hr cancellation policy I have read and understood the terms and conditions of my membership agreement and personal training terms and conditions CLIENT SIGNATURE CLIENT NAME DATE TRAINER SIGNATURE TRAINER NAME DATE 5 P a g e M o n t y P e r s o n a l T r a i n i n g
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