YMCA of Greater Houston. Personal Trainer Forms

Size: px
Start display at page:

Download "YMCA of Greater Houston. Personal Trainer Forms"

Transcription

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.

PERSONAL TRAINING CLIENT INFORMATION PACKAGE

PERSONAL TRAINING CLIENT INFORMATION PACKAGE PERSONAL TRAINING CLIENT INFORMATION PACKAGE At West Vancouver Community Services, our approach to health and fitness is balanced. Being healthy means adopting a lifestyle that strengthens the body and

More information

USC RECREATIONAL SPORTS

USC RECREATIONAL SPORTS USC RECREATIONAL SPORTS PERSONAL TRAINING INFORMATION PACKET WELCOME TO USC REC SPORTS PERSONAL TRAINING GETTING STARTED The information included in this packet is everything you need to get started with

More information

INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM

INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM NAME: DATE: 1. PURPOSE AND EXPLANATION OF PROCEDURE I hereby consent to voluntarily engage in an acceptable

More information

Personal Training Pre-Participation Packet

Personal Training Pre-Participation Packet Client name: W# Personal Trainer: Returning Client: YES or NO Personal Training Pre-Participation Packet Dear Client, Welcome to the Personal Training Program. We are excited that you have chosen to participate

More information

Pittsfield Family YMCA: Personal Training Services

Pittsfield Family YMCA: Personal Training Services Pittsfield Family YMCA: Personal Training Services I would like to purchase the following Client s Name personal training package with personal trainer : Trainer s Name 1 Session, $40 2 Sessions, $80 5

More information

PERSONAL TRAINING PACKET. Revised: 6/24/15

PERSONAL TRAINING PACKET. Revised: 6/24/15 PERSONAL TRAINING PACKET Revised: 6/24/15 Packages and Prices Advanced Trainer Rates: Advanced trainers are experienced trainers who hold a degree in Exercise/Fitness Science and/ or are certified though

More information

Certificate in Personal Training Case-Study Marking Checklist Unit Number: 500/8259/0of 2

Certificate in Personal Training Case-Study Marking Checklist Unit Number: 500/8259/0of 2 Candidate Name: Assessor Name: IV Name: Certificate in Personal Training Case-Study Marking Checklist Unit Number: 500/8259/0of 2 Date: Date: NB: Candidates must achieve enough passes to show competency

More information

Personal Training Health Screening Questionnaire

Personal Training Health Screening Questionnaire Personal Training Health Screening Questionnaire Personal Information Today s date: Title: Dr. Mr. Mrs. Ms. Name: / Birth date: Last name First name Age: Address: Phone: (home) City: Phone: (work) Province:

More information

PROGRAMMING PERSONAL TRAINING WITH CLIENTS

PROGRAMMING PERSONAL TRAINING WITH CLIENTS UNIT 5 PROGRAMMING PERSONAL TRAINING WITH CLIENTS This is a mandatory unit that is locally assessed and internally verified and subject to external verification by an OCR external verifier. The following

More information

RAM Personal Training

RAM Personal Training WEST CHESTER UNIVERSITY RAM Personal Training Division of Student Affairs Campus Recreation Dear MEMBER, Thank you for taking the first step towards better overall health and allowing the West Chester

More information

Guest Profile. Smart Start

Guest Profile. Smart Start 1111 Bagby St. Houston, TX 77002 713-651-0075 hfitness@plusone.com Monday Thursday: 5:30AM 9:00PM Friday: 5:30AM 8:00PM Saturday: Closed Sunday: Closed Guest Profile Mr. Ms. First Name: Last Name: of Birth:

More information

Step 1: Complete the attached Health Appraisal and Medical History Questionnaire, Goal Inventory, and Liability Waiver.

Step 1: Complete the attached Health Appraisal and Medical History Questionnaire, Goal Inventory, and Liability Waiver. Please use the contact information below for questions or concerns. Abraham Lincoln High School Name: Eric Nicholson Email: Eric_Nicholson@dpsk12.org Phone: 7204235043 Bruce Randolph School Name: Greg

More information

Recreation Oak Bay Personal Training CLIENT PACKAGE

Recreation Oak Bay Personal Training CLIENT PACKAGE Recreation Oak Bay Personal Training CLIENT PACKAGE Included in this package you will find: Par Q Health History Form Pricing Information Instructions: 1. Please read and complete each form accurately

More information

The HealthWizard 5 suite includes six programs: Health History. Fitness Profile. Wellness Profile. MicroFit Manager. SF-36 Health Survey

The HealthWizard 5 suite includes six programs: Health History. Fitness Profile. Wellness Profile. MicroFit Manager. SF-36 Health Survey HealthWizard 5 is a seamlessly integrated suite of six software programs designed for organizations that promote wellness and fitness. Offering maximum flexibility, the six program modules can be purchased

More information

Benefits of a Working Relationship Between Medical and Allied Health Practitioners and Personal Fitness Trainers

Benefits of a Working Relationship Between Medical and Allied Health Practitioners and Personal Fitness Trainers Benefits of a Working Relationship Between Medical and Allied Health Practitioners and Personal Fitness Trainers Introduction The health benefits of physical activity have been documented in numerous scientific

More information

Clinical Care Program

Clinical Care Program Clinical Care Program Therapy for the Cardiac Patient What s CHF? Not a kind of heart disease o Heart disease is called cardiomyopathy o Heart failure occurs when the heart can t pump enough blood to meet

More information

Application Form Single. Club Location The George Hotel, Chollerford. Members Details. Next of Kin Details. M/ship Type: Peak Off Peak 6 Week

Application Form Single. Club Location The George Hotel, Chollerford. Members Details. Next of Kin Details. M/ship Type: Peak Off Peak 6 Week Application Form Single Club Location The George Hotel, Chollerford. Members Details. M/ship Type: Peak Off Peak 6 Week Title: Surname: Fore Name(s): Date of Birth: Address: Postcode: Telephone Daytime:

More information

Personal Training Client Policies and Procedures

Personal Training Client Policies and Procedures Personal Training Client Policies and Procedures General Information Personal Trainers are certified through a nationally recognized personal training certification (ACSM, NSCA, ACE, AFAA, ISSA or equivalent).

More information

What is Physical Fitness?

What is Physical Fitness? What is Physical Fitness? Physical fitness is made up of two components: Skill-related fitness and Health related fitness. Skill related fitness items are factors, which relate to the possibility of you

More information

Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( )

Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( ) Patient Information Date: First Name: Address: Surname: City: Postal Code: Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone:

More information

University of North Georgia Recreational Sports Personal Training Information Sheet. 1 Session 3 Sessions 6 Sessions 10 Sessions Additional Training

University of North Georgia Recreational Sports Personal Training Information Sheet. 1 Session 3 Sessions 6 Sessions 10 Sessions Additional Training University of North Georgia Recreational Sports Personal Training Information Sheet The purpose of this program is to instruct beginning, intermediate, and advanced exercisers in the proper techniques

More information

Electronic Health Records Intake Form

Electronic Health Records Intake Form Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last

More information

HEALTH RISK ASSESSMENT (HRS) QUESTIONNAIRE

HEALTH RISK ASSESSMENT (HRS) QUESTIONNAIRE HEALTH RISK ASSESSMENT (HRS) QUESTIONNAIRE The Health Risk Assessment (HRA) questionnaire provides participants with an evaluation of their current health and quality of life. The assessment promotes health

More information

Pulmonary Rehabilitation Program - Home Exercise Program

Pulmonary Rehabilitation Program - Home Exercise Program Pulmonary Rehabilitation Program - Home Exercise Program Getting Started Regular exercise should be a part of life for everyone. Exercise improves the body's tolerance to activity and work, and strengthens

More information

West Florida Rehabilitation Institute Wellness Program

West Florida Rehabilitation Institute Wellness Program West Florida Rehabilitation Institute Wellness Program Thank you for your interest in our Wellness Program! As a member, you will enjoy the benefits of our modern Fitness Center and/or warm water pool.

More information

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( ) Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail

More information

Cardiac Rehabilitation

Cardiac Rehabilitation Cardiac Rehabilitation Exercise and Education Program Always thinking. Always caring. Cardiac Rehabilitation Dear Patient: Cardiac rehabilitation is an important part of your recovery. Our progressive

More information

*WELCOME TO OUR OFFICE*

*WELCOME TO OUR OFFICE* *WELCOME TO OUR OFFICE* WE FIND THAT COMMUNICATION WITH OUR PATIENTS REGARDING OUR BUISNESS OFFICE POLICIES ASSISTS US IN PROVIDING YOU THE BEST SERVICE. THEREFORE WE HAVE PROVIDED A HIGHLIGHT OF SOME

More information

Cardiac Rehabilitation. Exercise and Education Program

Cardiac Rehabilitation. Exercise and Education Program Cardiac Rehabilitation Exercise and Education Program Cardiac Rehabilitation Dear Patient: Cardiac rehabilitation is an important part of your recovery. Our progressive cardiac rehabilitation program

More information

Insomnia affects 1 in 3 adults every year in the U.S. and Canada.

Insomnia affects 1 in 3 adults every year in the U.S. and Canada. Insomnia What is insomnia? Having insomnia means you often have trouble falling or staying asleep or going back to sleep if you awaken. Insomnia can be either a short-term or a long-term problem. Insomnia

More information

New England Pain Management Consultants At New England Baptist Hospital

New England Pain Management Consultants At New England Baptist Hospital New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants

More information

American Council on Exercise Certified Personal Trainer Certification Course 16 th October 2015 to 13 th December 2015

American Council on Exercise Certified Personal Trainer Certification Course 16 th October 2015 to 13 th December 2015 Call 6423 0668 now for more information or email enquiry@isa.edu.sg Registration closing date: 6 th October 2015 (Registration will close when we have reached a maximum class capacity.) American Council

More information

Tymikia S. Glenn, BS ACSM CPT Fitness and Membership Director Milan Family YMCA

Tymikia S. Glenn, BS ACSM CPT Fitness and Membership Director Milan Family YMCA Tymikia S. Glenn, BS ACSM CPT Fitness and Membership Director Milan Family YMCA Benefits of Starting an Exercise Program 1. Helps build and maintain healthy bones, muscles and joints 2. Reduces feelings

More information

PERSONAL TRAINING FITNESS ASSESSMENT

PERSONAL TRAINING FITNESS ASSESSMENT PERSONAL TRAINING FITNESS ASSESSMENT A fitness assessment is a great way to evaluate your current fitness level. It includes a series of measurements that help determine physical fitness and are a great

More information

AMERICAN COUNCIL ON EXERCISE Certified Personal Trainer Course Recognized by the fitness industry worldwide

AMERICAN COUNCIL ON EXERCISE Certified Personal Trainer Course Recognized by the fitness industry worldwide NEXT INTAKE 14 Aug 2015 to 17 Oct 2015 Registration Deadline: 07 Aug 2015 AMERICAN COUNCIL ON EXERCISE Certified Personal Trainer Course Recognized by the fitness industry worldwide This course is designed

More information

History Questionnaire

History Questionnaire History Questionnaire Today s Date Physician Patient Information Patient s Name Is this your legal name? Street Address Mr. Miss. Marital Status (circle one) Mrs. Ms. Single Mar Div Sep Wid If not, what

More information

Medical Massage Client Intake Form Medical Massage Client Intake Form

Medical Massage Client Intake Form Medical Massage Client Intake Form Medical Massage Client Intake Form Medical Massage Client Intake Form Client Name: Date: Please note: The more information you are able to provide, the better equipped our therapists will be to help you.

More information

CPT. Content Outline and Domain Weightings

CPT. Content Outline and Domain Weightings Appendix J CPT Content Outline and Domain Weightings National Academy of Sports Medicine (NASM) Page 147 National Academy of Sports Medicine - Certified Personal Trainer (CPT) Content Outline Domain I:

More information

WELCOME TO YMCA Teen Scene Middle School Enrichment Program (This sheet is for parents to keep for informational purposes)

WELCOME TO YMCA Teen Scene Middle School Enrichment Program (This sheet is for parents to keep for informational purposes) Robert D. Fowler Family YMCA Middle School Enrichment Program Student Registration Form 2015-16 Ivy Prep Academy Program Hours: 7am-7:45am & 4pm-7pm Transportation AM: Group leaves at 7:30am Transportation

More information

MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE

MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital

More information

Exercise. Good Weight A PT E R. Staying Healthy

Exercise. Good Weight A PT E R. Staying Healthy Eat Healthy Foods Keep at a Good Weight Exercise Don t Smoke Get Regular Checkups Take Care of Stress A PT E R CH Staying Healthy 6 81 How Can I Stay Healthy? You can do many things to prevent poor health

More information

CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850

CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850 CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850 TELEPHONE: (607) 252-3590 FAX: 607-252-3592 An appointment

More information

PERSONAL TRAINING INTRODUCTION & POLICIES

PERSONAL TRAINING INTRODUCTION & POLICIES PERSONAL TRAINING INTRODUCTION & POLICIES A Message from the Assistant Director for Fitness/Wellness Campus Recreation at UMass Amherst is pleased that you are interested in training with us. Our goal

More information

Here at PhysioDC we are committed to providing you with excellent care.

Here at PhysioDC we are committed to providing you with excellent care. Washington PhysioDC 1001 Connecticut Ave. NW Suite 330 Washington, DC 20036 202-223-8500 202-379-9299 (fax) physiodc@gmail.com CANCELLATION POLICY EFFECTIVE 2016 Here at PhysioDC we are committed to providing

More information

Welcome to Crozer-Keystone Health Network Primary Care

Welcome to Crozer-Keystone Health Network Primary Care Welcome to Crozer-Keystone Health Network Primary Care A Guide to Your CKHN Patient-Centered Medical Home: What you can expect from us... What we will need from you......so you can gain the full benefits

More information

1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074

1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074 Locations 1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074 2 East 328 S. Woodcrest Drive, Bloomington, IN 47401 t 812.353.3278 866.353.3278 3 West 2499 W. Cota Drive,

More information

Personal/Athletic Training Agreement

Personal/Athletic Training Agreement Personal/Athletic Training Agreement Standard Fitness Training ½ Hour Session Total Package Cost Price Per Session Expiration Terms Packages 10 Sessions $300 $30.00 Sessions expire 10 weeks 20 Sessions

More information

Physical Activity and Weight Control

Physical Activity and Weight Control Physical Activity and Weight Control WIN Weight-control Information Network U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH Physical Activity and Weight Control Physical activity

More information

USCGA Health and Physical Education Fitness Preparation Guidelines

USCGA Health and Physical Education Fitness Preparation Guidelines USCGA Health and Physical Education Fitness Preparation Guidelines MUSCULAR STRENGTH Muscular strength and endurance can be improved by systematically increasing the load (resistance) that you are using.

More information

Personal Fitness Plan

Personal Fitness Plan Personal Fitness Plan 7 th Grade 1 week plan/1 week food log Name Period 0 1 2 3 4 5 6 7 Date When you complete this project, you will accomplish the following: Set specific short-term and long-term personal

More information

PATIENT REGISTRATION

PATIENT REGISTRATION Orthopedic & Sports Therapy Center PATIENT REGISTRATION NAME DATE OF BIRTH SSN# FIRST MI LAST PHONE INFO: HOME BEST WAY TO CONFIRM APPOINTMENTS WORK CALL TEXT EMAIL MOBILE (TEXT) MOBILE CARRIER EMAIL ADDRESS

More information

High Blood Pressure (Essential Hypertension)

High Blood Pressure (Essential Hypertension) Sacramento Heart & Vascular Medical Associates February 18, 2012 500 University Ave. Sacramento, CA 95825 Page 1 916-830-2000 Fax: 916-830-2001 What is essential hypertension? Blood pressure is the force

More information

If yes, you are not eligible to participate in this program)

If yes, you are not eligible to participate in this program) Patient Name: Date: Address: City: St: Zip: Email Address: Ok to send email: Yes No Phone: Date Of Birth: How did you find out about our weight loss program? Are you currently pregnant, breast feeding,

More information

VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions

VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions 18 HEALY DR. WINSTON SALEM, NC 710 PH. 6-768-50 FAX- 768-19 Scott W. Baker, MD Patient Instructions 1. Bring a list of all regular medications and dosages.. Bring your insurance card and all necessary

More information

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:

More information

GENERAL HEART DISEASE KNOW THE FACTS

GENERAL HEART DISEASE KNOW THE FACTS GENERAL HEART DISEASE KNOW THE FACTS WHAT IS Heart disease is a broad term meaning any disease affecting the heart. It is commonly used to refer to coronary heart disease (CHD), a more specific term to

More information

Health History and Review of Systems (Please check all that apply)

Health History and Review of Systems (Please check all that apply) Health History and Review of Systems (Please check all that apply) Last Name: First Name: Date of Birth: / / q Male q Female Age: Marital Status: q Single q Married q Divorced q Separated q Widowed Who

More information

Exercise Prescription Case Studies

Exercise Prescription Case Studies 14 Exercise Prescription Case Studies 14 14 Exercise Prescription Case Studies Case 1 Risk Stratification CY CHAN is a 43-year-old man with known history of hypertension on medication under good control.

More information

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER

More information

460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 info@physiotherapyclinic.ca

460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 info@physiotherapyclinic.ca Page 1 of 6 Date Patient Information (Please complete all fields below) Last Name First Name Intl. Street Address Home Tel. City/Town Province Postal Code Work Tel. Date of Birth (mm/dd/yyyy) Gender M

More information

Easy Read. How can we make sure everyone gets the right health care? How can we make NHS care better?

Easy Read. How can we make sure everyone gets the right health care? How can we make NHS care better? Easy Read How can we make NHS care better? How can we make sure everyone gets the right health care? What can we do to make the NHS good now and in the future? How can we afford to keep the NHS going?

More information

Hands-On Care Physical Therapy P.C PhysioCare Physical Therapy P.C EXPLANATION OF PROCEDURES

Hands-On Care Physical Therapy P.C PhysioCare Physical Therapy P.C EXPLANATION OF PROCEDURES EXPLANATION OF PROCEDURES Welcome to our practice. You are here because you have been referred to us by your doctor for Physical Therapy. Physical Therapy is defined as: The evaluation, treatment or prevention

More information

New Patient Form Please print clearly

New Patient Form Please print clearly New Patient Form Today s Date: Name: Last First MI Preferred name to be called: Email: Address: Street City State Zip DOB: Age: Sex: SSN#: - - Please check a box for the preferred # to call to confirm

More information

THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History

THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History Name DOB Date Age Occupation Email Address Home address City State Zip Home phone Cell Phone Referred By Physician Physician Phone Please

More information

Orthopedic Initial Questionnaire

Orthopedic Initial Questionnaire Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

More information

Quit & Get Fit! Frequently Asked Questions For Personal Trainers (November 2011)

Quit & Get Fit! Frequently Asked Questions For Personal Trainers (November 2011) Quit & Get Fit! Frequently Asked Questions For Personal Trainers (November 2011) What is Quit & Get Fit? Quit & Get Fit is an initiative of the Ontario Lung Association, made possible through funding from

More information

The Paramedic Candidate Physical Abilities Test (PC-PAT)

The Paramedic Candidate Physical Abilities Test (PC-PAT) The Paramedic Candidate Physical Abilities Test (PC-PAT) Information Package Developed and Administered for Emergency Medical care Inc. by The Paramedic Candidate Physical Abilities Test A partnership

More information

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other: At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We

More information

X Guarantor/Parent/Guardian Signature

X Guarantor/Parent/Guardian Signature Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency

More information

Thank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you!

Thank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you! Thank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you! To simplify the registration process during your first visit we ask that you take a moment

More information

Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use

More information

Blood Pressure Assessment Program Screening Guidelines

Blood Pressure Assessment Program Screening Guidelines Blood Pressure Assessment Program Screening Guidelines Assessment Pre-Assessment Prior to/during assessment, explain to client the following: What is meant by high blood pressure; What are the effects

More information

Texas Education Agency OP 07-43 Operating Procedures Page 1 OP 07-43 WORKSITE WELLNESS PROGRAM

Texas Education Agency OP 07-43 Operating Procedures Page 1 OP 07-43 WORKSITE WELLNESS PROGRAM Texas Education Agency OP 07-43 Operating Procedures Page 1 OP 07-43 WORKSITE WELLNESS PROGRAM 1. Purpose. Establish a Worksite Wellness Program to foster the adoption of a wellness culture in order to

More information

8th Grade Personal Fitness Plan

8th Grade Personal Fitness Plan 8th Grade Personal Fitness Plan 2 Week Activity Log & 1 week Food Log Name: Period: Date: Personal Fitness Contract I,, am going to make a commitment to helping build my lifelong fitness and nutrition

More information

Orthopedic Initial Questionnaire. Date: Weight:

Orthopedic Initial Questionnaire. Date: Weight: Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

More information

Patient Questionnaire for Men

Patient Questionnaire for Men Patient Questionnaire for Men Please fill out the following questionnaire to the best of your ability prior to your first appointment. Your physical therapist will review your responses during your initial

More information

How To Get A Membership At Angelina Rehabilitation Center

How To Get A Membership At Angelina Rehabilitation Center APPLICATION FOR MEMBERSHIP.. Member Information Referring Physician Name:,, (Last) (First) (Middle) Driver s License #: Sex: M /F: Date of Birth: Social Security #: Email Address: Home Address: City: State:

More information

PAIN MANAGEMENT. Patient s name: IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.

PAIN MANAGEMENT. Patient s name: IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT. PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and Reports of any X- rays, MRI or Cat scans. Patient s name:

More information

Patient Information. and Physical Activity Diary. Wythenshawe Hospital Cardiac Rehabilitation. Name:... The ticker club Registered Charity No.

Patient Information. and Physical Activity Diary. Wythenshawe Hospital Cardiac Rehabilitation. Name:... The ticker club Registered Charity No. Wythenshawe Hospital Cardiac Rehabilitation Patient Information Remember : Lifelong regular physical activity - 0 minutes, five times per week is important for your general health. I feel so much better

More information

Fit for Flight. Developing a Personal Fitness Program

Fit for Flight. Developing a Personal Fitness Program Fit for Flight Developing a Personal Fitness Program The purpose of this brochure is to provide you with basic guidelines for developing a balanced physical fitness program and customizing a workout to

More information

Emory Eye Center New Patient Questionnaire

Emory Eye Center New Patient Questionnaire Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions

More information

Health Risk Appraisal Profile

Health Risk Appraisal Profile Language (Character Set): Health Risk Appraisal Profile Congratulations for completing your Health Risk Appraisal Questionnaire! Last update: June 4, 2012; 8:27:54 CDT This Health Risk Appraisal is not

More information

NEW STUDENT-ATHLETE MEDICAL HISTORY FORM

NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Student-Athlete Information NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Name Date Birth SSN Sport Student ID Number Academic Class 1 Personal Physician s Name Phone # Person to Contact In The Event of Emergency

More information

Medical History Questionnaire

Medical History Questionnaire Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of

More information

Throughout this reference summary, you will find out what massage therapy is, its benefits, risks, and what to expect during and after a massage.

Throughout this reference summary, you will find out what massage therapy is, its benefits, risks, and what to expect during and after a massage. Massage Therapy Introduction Massage therapy is the manipulation of the soft tissues of the body, including the skin, tendons, muscles and connective tissue by a professional, for relaxation or to enhance

More information

Pitcairn Medical Practice New Patient Questionnaire

Pitcairn Medical Practice New Patient Questionnaire / / *Areas are mandatory. Failure to complete may delay the time taken to process your registration *Surname: *Forename(s): *Address: *Date of Birth/CHI: / Marital Status: Sex: Male / Female (delete as

More information

CARDIAC OR PULMONARY HISTORY

CARDIAC OR PULMONARY HISTORY Name: Last First M Gender: M / F DOB: / / Age: Email Address: Address: City State Zip Preferred Contact Number: ( ) - Alternative Contact Number: ( ) - Emergency Contact: Relationship: Name Emergency Contact

More information

DIABETES MELLITUS. By Tracey Steenkamp Biokineticist at the Institute for Sport Research, University of Pretoria

DIABETES MELLITUS. By Tracey Steenkamp Biokineticist at the Institute for Sport Research, University of Pretoria DIABETES MELLITUS By Tracey Steenkamp Biokineticist at the Institute for Sport Research, University of Pretoria What is Diabetes Diabetes Mellitus (commonly referred to as diabetes ) is a chronic medical

More information

Form ### Transgender Hormone Therapy - Estrogen Informed Consent SAMPLE

Form ### Transgender Hormone Therapy - Estrogen Informed Consent SAMPLE What are the different medications that can help to feminize me? Estrogen - Different types of the hormone estrogen can help you appear more feminine. Estrogen is the female sex hormone. Androgen blocker

More information

DISCOUNTED GIFT & INCOME TRUST UNDERWRITING/HEALTH QUESTIONNAIRE

DISCOUNTED GIFT & INCOME TRUST UNDERWRITING/HEALTH QUESTIONNAIRE DISCOUNTED GIFT & INCOME TRUST UNDERWRITING/HEALTH QUESTIONNAIRE 1. TYPE OF UNDERWRITING REQUIRED Please tick one box only A. Full advance underwriting required (you must now complete this form) If the

More information

Dr. Kenneth A. Giraldo, MD, P.A. Patient Controlled Substance Agreement Informed Consent Form

Dr. Kenneth A. Giraldo, MD, P.A. Patient Controlled Substance Agreement Informed Consent Form Dr. Kenneth A. Giraldo, MD, P.A. Patient Controlled Substance Agreement Informed Consent Form The following agreement relates to my use of controlled substance for chronic pain prescribed by Dr. Kenneth

More information

UNIVERSAL FITNESS NETWORK, Inc. 2315 West Monica Dunlap, IL 61525 (309)-360-5615 bahenso@comcast.net FACTS ABOUT THE PHYSICAL FITNESS ASSESSMENT TESTS

UNIVERSAL FITNESS NETWORK, Inc. 2315 West Monica Dunlap, IL 61525 (309)-360-5615 bahenso@comcast.net FACTS ABOUT THE PHYSICAL FITNESS ASSESSMENT TESTS UNIVERSAL FITNESS NETWORK, Inc. 2315 West Monica Dunlap, IL 61525 (309)-360-5615 bahenso@comcast.net FACTS ABOUT THE PHYSICAL FITNESS ASSESSMENT TESTS Universal Fitness Network, Inc. specializes in physical

More information

AON Physical Therapy & Wellness

AON Physical Therapy & Wellness AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?

More information

2015-16 CHECKLISTS OF ATHLETIC TRAINING INFORMATION

2015-16 CHECKLISTS OF ATHLETIC TRAINING INFORMATION 2015-16 CHECKLISTS OF ATHLETIC TRAINING INFORMATION Returning GCU Student Athletes: Until these forms are complete and you have been released to practice by the Athletic Training Staff, you will not be

More information

Freedom Hearing Center LLC

Freedom Hearing Center LLC 14090 H.G. Trueman Road, Suite 1400 Solomons, MD 20688 410-610- 2246 Rebecca L Jahed, AuD, FAAA Welcome to Freedom Hearing Center. My name is Dr. Rebecca L. Jahed and I am the President of this private

More information

SIS30310 : Certificate III in Fitness. Notebook

SIS30310 : Certificate III in Fitness. Notebook SIS30310 : Certificate III in Fitness Notebook SISFFIT301A Provide fitness orientation and health screening 1 SISFFIT301A :Provide fitness orientation and health screening Client orientation, induction

More information

Municipal Police Officers Education and Training Commission Physical Fitness Test Battery Protocols and Guidelines

Municipal Police Officers Education and Training Commission Physical Fitness Test Battery Protocols and Guidelines Municipal Police Officers Education and Training Commission Physical Fitness Test Battery Protocols and Guidelines The safety of all applicants and cadets is of the utmost importance. All applicants and

More information

MILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE

MILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE MILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS. To register with the Practice please complete this questionnaire as fully as possible.

More information

IHSA Sports Medicine Acknowledgement & Consent Form. Concussion Information Sheet

IHSA Sports Medicine Acknowledgement & Consent Form. Concussion Information Sheet Concussion Information Sheet A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force

More information

Personal Training Agreement

Personal Training Agreement Personal Training Agreement This Personal Training Agreement, (hereinafter, the Agreement) is made and entered into on this date, by and between Toned 'n Tuff, LLC and (hereinafter, the Client). Trainer

More information