YMCA of Greater Houston. Personal Trainer Forms
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1 YMCA of Greater Houston Personal Trainer Forms Revised June 2011
2 YMCA Personal Training Questionnaire Congratulations on your commitment to a lifestyle of Health and Wellness. To help us best structure a plan specifically designed to fit your needs, please answer the following questions to the best of your ability. Name: Date: Home Phone: Work Phone: DOB: Address: Age: Address: Employer/Occupation: How many hours do you work per week? < > 50 What are the primary physical requirements of your job? Phone/computer Sitting Standing Lifting Travel Please rate your level of stress on the following scale (circle one) Home: Low Stress High Stress Work: Low Stress High Stress Please list a relative whom we may contact in case of an emergency. Name: Home Phone: Relation: Work Phone: Please complete the information for your personal physician. Name of Physician: Address: Office Phone: Office Fax: Page 1
3 Family Health History Please indicate if you have any primary relatives who have any of the following conditions. (check all that apply) Asthma Cancer Hypertension High Cholesterol Arthritis Diabetes Heart Disease Osteoporosis Obesity Stroke Other: Please provide a brief explanation for any of the above that have been checked. Personal Health History Please indicate if you have any of the following conditions. (check all that apply). Asthma Cancer Hypertension High Cholesterol Arthritis Diabetes Heart Disease Osteoporosis Obesity Stroke Other: Please provide a brief explanation for any of the above that have been checked. Please indicate if you have had any joint injuries or surgeries that may limit or affect your ability to exercise. Neck Hip Wrist/Hand Shoulder Knee Ankle/Foot Elbow Low Back Other Please provide a brief explanation for any of the above that have been checked. Please indicate any medications currently used. Type of Medication Purpose Page 2
4 Do you smoke cigarettes? Yes No If yes, how often? Are you a past smoker? Yes No If yes, when did you quit? Do you drink alcoholic beverages? Yes No If yes, how much, often? Are you presently dieting or on a weight control program? Yes No If yes, please provide a brief explanation. Do you have any past or present medical conditions, not already addressed, which may influence your ability to safely participate in an exercise program? If yes, please explain. Please provide a brief explanation of your current exercise program. Include types of activity and frequency. What are your current health and fitness goals? Please be as specific as possible. Do you foresee any barriers that may prevent you from adhering to a regular exercise program? How do you rate your level of motivation and commitment to achieving your goals? (circle one) Low High Have you worked with a personal trainer in the past? Yes No When are you available to meet with a trainer? Morning Day Evening Other: Do you prefer to work with a male or female trainer? Male Female No preference How did you hear about YMCA Personal Training? Brochure/Flyer Referral from friend YMCA staff Promotional offer YMCA Website Other: Page 3
5 PAR-Q & YOU (A Questionnaire for People Aged 16 to 69) Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor first. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO. YES NO 1.Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? 2.Do you feel pain in your chest when you do physical activity? 3. In the past month, have you had chest pain when you were not doing physical activity? 4. Do you lose you balance because of dizziness or do you ever lose consciousness? 5. Do you have a bone or join problem that could be made worse by a change in your physical activity? 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? 7. Do you know of any other reason why you should not do physical activity? IF YOU ANSWERED YES to one or more questions Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. Find out which community programs are safe and helpful to you. NO to all questions If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can. Start becoming more physically active - begin slowly and build up gradually. This is the safest and easiest way to go. Take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. DELAY BECOMING MUCH MORE ACTIVE: If you are not feeling well because of a temporary illness such as a cold or a feverwait until you feel better; or If you are or may be pregnant-talk to your doctor before you start becoming more active. Please Note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change you physical activity plan. Informed use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for person(s) who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity. Participant s Signature: Date:
6 Informed Consent for Fitness Testing and Exercise Participation Name: (please print) I. Fitness Testing The purpose of the fitness-testing program is to evaluate cardio-respiratory fitness, body composition, flexibility and muscular strength and endurance. The cardio-respiratory fitness test involves a submaximal test that may include a bench step test, a cycle ergometer test, or a one-mile walk test. Body composition is analyzed by taking several skinfold measure to calculate percentage of body fat. Flexibility is determined by the sit-and-reach test. Muscular strength may be determined by an upper-body bench press test or a lower-body leg extension test. Muscular endurance may be evaluated by the one-minute, bent-knee sit-up test or the endurance bench press test. II. Exercise Participation I desire to engage voluntarily in the YMCA exercise program in order to attempt to improve my physical fitness. I understand that the activities are designed to place a gradually increasing workload on the cardiorespiratory system and thereby attempt to improve its function. The reaction of the cardiorespiratory system to such activities cannot be predicted with complete accuracy. There is a risk of certain changes that might occur during or following exercise. These changes might include abnormalities of blood pressure or heart rate. I understand that the purpose of the exercise program is to develop and maintain cardiorespiratory fitness, body composition, flexibility and muscular strength and endurance. A specific exercise plan will be given to me, based on my needs and interests and my doctors recommendations. All exercise programs include warm-up, exercise at target heart rate and cool down. The programs may involve walking, jogging, swimming, or cycling (outdoor and stationary); participation in exercise fitness, rhythmic aerobic exercise, or choreographed fitness classes; or calisthenics or strength training. All programs are designed to place a gradually increased workload on the body in order to improve overall fitness. The rate of progression is regulated by exercising to target heart rate and rate of perceived exertion. I affirm that I am responsible for monitoring my own condition throughout the tests and/or exercise program, and should any unusual symptoms occur, I will cease my participation and inform my instructor of the symptoms. In signing this consent form, I affirm that I have read this form in its entirety and that I understand the description of the tests and their components. I also affirm that my questions regarding the fitness-testing program have been answered to my satisfaction. In the event that a medical clearance must be obtained prior to my participation in the fitness-testing program, I agree to consult my physician and obtain written permission from my physician prior to the commencement of any fitness tests. Also, in consideration for being allowed to participate in the fitness training and/or exercise program, I agree to assume the risk of such testing or exercise, and further agree to hold harmless the YMCA and its staff members conducting such testing and/or the exercise program from any and all claims, suits, losses, or related causes of action for damages, including, but not limited to, such claims that may result from injury or death, accidental or otherwise, during, or arising in any way from the testing or exercise program. Signature of Participant Date Person Administering Test Date Personal Trainer Date
7 Notice of Understanding and Consent (This must be signed by all personal training participants) By signing this consent, I acknowledge that I am informed of the following: 1. All pre-paid personal training sessions must be used within six (6) months of purchase. Prior to the six month expiration, you, the client, may arrange with your trainer, at your trainer s discretion, to extend sessions past one year. If such arrangement is not made, all sessions not used within one year are automatically forfeited without further notice to you, the client. 2. No refunds are given for unused, prepaid sessions for any reason. 3. Please be advised that training sessions may be rescheduled; however, you must give no less than 24 hours notice to your trainer if you cannot make a session. If you give less than 24 hours notice, or if you do not show up for a session, you will be held responsible for payment of that missed session. I _ understand and agree to the terms of this understanding and consent. I will abide by such terms in order to begin and successfully continue my personal training program after it is initiated. I understand that I may discontinue training at any time without a refund of prepaid sessions. Signature of Participant Date
8 Dear Client: Personal Training Payment & Cancellation Policy The session you have scheduled is reserved for you. Other appointments are not scheduled due to your reserved training time. Individual Training Any client not canceling an appointment at least 24 hours in advance will be charged the entire cost of the session. If you need to cancel an appointment, please contact your trainer as soon as possible. Your early notification increases the possibility of offering that appointment to another client. Please also note that if you forget to attend your session, you will be charged for the entire session. Partner or Group Training Payment for group training packages is due one week prior to the group start date. Individuals withdrawing from a group less than one week prior to the group start date will be charged half the package fee. There will be no rescheduled appointments (payment is forfeited) if you have scheduled training sessions along with a group or other participants and fail to participate at the time of your scheduled appointment. No refunds will be given after 30 days from date of purchase. Thank you for your consideration on this matter. X CLIENT SIGNATURE DATE YMCA Mission: To put Judeo-Christian principles into practice through programs that build healthy spirit, mind and body for all. Everyone is welcome.
9 YMCA Health/Fitness Pre-participation Medical Clearance Form To: From: Physician: Name: Clinic: Branch: Address: Address: Phone: Phone: Fax: Fax: Date: Dear, Your patient, (DOB), has applied for enrollment in the fitness testing and/or exercise programs at the YMCA. The fitness testing may involve a submaximal test for cardiorespiratory fitness, body composition analysis, flexibility test, and a muscular strength and endurance tests. The exercise programs are designed to start easy and become progressively more difficult over a period of time. A more detailed description of the fitness testing protocols and exercise programs is available upon request. Qualified personnel trained in conducting exercise tests and exercise programs will administer all fitness tests and programs. All fitness instructors are certified in CPR, standard first aid and the use of an AED. By completing the box below, however, you are not assuming any responsibility for our administration of the fitness testing and/or exercise programs. If you know of any medical or other reasons why participation in the fitness testing and/or exercise programs by the applicant would be unwise, please indicate so on this form. If you have any questions regarding the YMCA fitness testing and/or exercise programs, please feel free to call me at _. Report of Physician I know of no reason why the applicant may not participate in the fitness testing and/or exercise program. I believe the applicant may participate, but I recommend the following guidelines and precautions be observed. The applicant should not engage in the following activities. I recommend that the applicant NOT participate. Physician Signature: Date:
10 Training Session Ledger Name: No. Date Time In Time Out Fee Payment Notes Log #
11 Client Name: Date Notes
12 Resistance Training Log Name: Cardiovascular Equipment Date: T D T D T D T D T D T D T D Resistance Training Exercise W S R W S R W S R W S R W S R W S R W S R Total Cardio Time/ # of Sets
13 YMCA Personal Training Monthly Session Log Trainer: Month/Year: Branch: _ Date Member s Name Type of Service Session # PT Other Notes: Total Personal Training Sessions: Total Other Fitness Appointments: Total Number of Appointments:
14 YMCA of Greater Houston PERSONAL TRAINING PARTICIPANT Your input is important to the continued success and improvement of our Personal Training Program. We appreciate your feedback and comments regarding your experience with YMCA Personal Training. Please take a moment to complete the following evaluation and return to_. Name of Personal Trainer Branch: _ Please rate the following statements using the scale to the right. POOR FAIR AVERAGE GOOD EXCELLENT 1. The availablitity of your trainer on days and times convenient for your schedule. 2. The knowledge and skills of your personal trainer. The trainers ability to communicate opening and 3. clearly The trainers ability to develop and modify your exercise program based on your individual goals, desires, and possible limitations. The trainers ability to keep you motivated and help you stay consistent with your exercise program. 6. The personal trainer was professional and punctual. 7. The exercise program met your goals and objectives. Please answer the following questions by checking the appriopriate box to the right. YES NO 8. Did the YMCA personal training program meet your expectations? 9. Was the value of your personal training consistent with the cost? 10. Would you recommend the YMCA Personal Training services to a friend or family member? 11. Do you feel that your trainer postively represented the image of the YMCA? What impact has your trainer made in your life when 12. it comes to your health and wellness? Additional Comments/Suggestions: Thank you for taking the time to complete this questionaire.
15 PERSONAL TRAINING DEPARTMENT PEER EVALUATION Name of Evaluator: Date: Personal Trainer: Client: Models the values of the YMCA (faith, responsibility, respect, honesty and caring) Arrives early and prepared for session Appropriate attire, hygiene and speech Gives a warm greeting to client Teaches exercises using an appropriate style (explain, demonstrate, client practices, quizzing) Offers regular and appropriate eye contact Body language demonstrates focus and attention on client Offers regular positive feedback and regularly looks for and acknowledges client success Uses client s name regularly Offers at least one new exercise, a new fitness fact, or provides written literature for client Displays an exceptional knowledge of anatomy and biomechanics of movement Exercise choices are safe and exercise sequence effective Method of tracking client progress Is professional and effective Gives something for client to work on until next session 1. The things I thought were terrific about your session: 2. Questions I have regarding your session: 3. My ideas for improvement: 4. Two goals to work on in the next 3-6 months: 1. 2.
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