PERSONAL TRAINING CLIENT PAPERWORK
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1 PERSONAL TRAINING CLIENT PAPERWORK Client s Name: Phone:
2 CLIENT INFORMATION Name: Member Number: Date of Birth: Street Address: City/State: Circle: Male Female Current Age: Name of Emergency Contact: Cell/Home Phone Number: Today s Personal Trainer: Height: Weight: Blood Pressure: Informed Consent I hereby request the opportunity to participate in a health and fitness evaluation consisting of physical exercise. I hereby acknowledge that my participation in this evaluation is entirely voluntary on my part. Such participation is solely for my own pleasure and benefit. It is possible that certain unhealthy changes may occur during this evaluation which may include: Abnormal blood pressure Fainting Disorder of heart beat Heart attack or stroke Information you possess about your health status or previous experiences of unusual feeling with physical effort may affect the safety and value of your evaluation. Your prompt reporting of feelings with effort during the evaluation are also of great importance. You are responsible to fully disclose such information when request by the testing staff. Any questions about the procedures used in the evaluation are encouraged. If you have any doubts or questions, please ask us for further explanation. Your permission to perform this evaluation is voluntary. You are free to deny consent or stop the evaluation at any point. I have read this form and I understand the testing procedures that I will perform. I consent to participate in this evaluation. Member Signature: Personal Trainer Signature:
3 HEALTH HISTORY QUESTIONNAIRE Date of last physical exam: Clinic: Please list any medications and/or supplements you are currently taking. Please include frequency and dose. Have you ever been or are currently diagnosed with the following? ARTHRITIS BACK PROBLEMS BONE/JOINT OR MUSCULAR ISSUES PREGNANCY *CURRENT OR PLANNING TO BECOME HYPERTENSION HEART MURMUR HIGH CHOLESTROL DIABETES *Type 1 or 2 ASTHMA OTHER: (Please include any surgeries, hospitalizations or any other diagnoses) If you have two or more high risk factors, a Medical Clearance is required before testing or training occur. If there are any changes to your health, please notify your Personal Trainer immediately.
4 Client Goal Profile To best assist you in achieving your goals and getting the most out of your personal training sessions, please fill out the following information. What are your specific health and wellness goals? Check all that apply Lose weight Rehabilitation for injury Improve motivation Learn more about fitness Improve strength Gain muscle mass Improve sport performance Improve self-confidence Reduce stress Decrease health metrics *BP, cholesterol, glucose (etc.) Are you currently engaged in regular physical activity? YES (details): How many days do you feel you can dedicate to improving your physical activity? Do you feel like you need assistance with a nutrition program? Please list any goal that you would like to achieve: NO EXPLAIN: YES (details): NO
5 PERSONAL TRAINING CANCELLATION/REFUND POLICY Personal training is a time commitment for members as well as trainers. Dakotah! Sport & Fitness utilizes a cancellation and refund policy for all personal training sessions. To cancel a Personal Training Session, you must notify your trainer 24 hours in advance: Call the Fitness Desk Call the trainer directly If you fail to give a 24-hour notice, you will be charged your full session rate. *Exceptions to this policy include illness and family emergencies. Refund Policy: Full refunds will be given for medical reasons. A physician s notice stating the reason the member is unable to complete the sessions by the expiration date must accompany the refund request. All other requests for refunds for any other reason will be given at 50% of the remaining balance at the discretion of Dakotah! Sport & Fitness. I have read the above cancellation and refund policy and agree with the policy terms. Member Signature: Printed Name of Member: Personal Trainer Signature: Printed Name of Personal Trainer:
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