Personal Training Health Screening Questionnaire
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1 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: Postal Code: Phone: (cell): Fax: Occupation: Gender: Male Female Height: Weight: Person to contact in case of emergency: Tel: Physician s Name: Tel: May I send a copy of your consultation to your physician &/or physical therapist? Yes No Bus: Fax: Page 1 of 5
2 Medical History Please indicate if any of these statements apply to you by placing a YES in the space provided (*past or current): 1. History of heart problems (ie. chest pains, heart murmur, or stroke) 2. Diabetes Mellitus 3. Asthma, breathing or lung problems 4. Allergies 5. Cancer (other than skin) 6. Seizures, seizure medication, neurological problems or dizziness 7. High blood pressure 8. Back problem, joint or muscle disorder still affecting you 9. Recent surgery (last 12 months) 10. Hernia or any condition that may be aggravated by exercise 11. Physician s advice not to exercise 12. History of high cholesterol 13. Family history of coronary heart disease? 14. Do you smoke tobacco products? 15. Do you consume alcohol? 16. Do you take supplements of any kind? 17. Are you on medication? 18. Do you have a joint problem that might be aggravated by exercise? 19. Is stress from daily living an issue in your life? Skeletal Injuries Back Neck Head Knee (R, L) Shoulder (R, L) Other Injuries: Surgery: Please describe any special considerations or how your injury currently affects your ability to function: (i.e. Illness or injury) Bus: Fax: Page 2 of 5
3 Please talk with your doctor by phone or in person before you start any new training program or have a fitness appraisal. Tell your doctor about your health questionnaire and which questions you answered yes. Goals 1. What are your concerns and goals? (examples: fat loss, strength, power, muscular endurance, cardio fitness, flexibility, agility, core stability or balance) 2. Why do you want to achieve these goals? (examples: general health, injury prevention/rehab, sport-specific training, aesthetic reasons) 3. Which criteria will you use to measure the effectiveness of this program? (examples: body measurements/%, sport-specific goals, increased energy level, stress reduction) 4. What areas do you want to concentrate on or emphasize? (i.e.: specific areas to strengthen, joint stability, cardio or core conditioning, specific areas to mobilize). Fitness History 5. How long has it been since you have exercised regularly? (2 or more times/week). 6. Do you have experience with free weights or functional stability training? 7. What type of cardiovascular exercise are you familiar with? 8. If you are an experienced exerciser or athlete, what exactly is your current program? Bus: Fax: Page 3 of 5
4 9. Are there any exercises that are contraindicated or not recommended by your physician or physical therapist? Lifestyle 10. How would you describe your level of daily activities? Light (office work) Moderate (manual labor) Heavy (construction) 11. Stress (high=5, low=1) Physical Personal/Emotional Mental/Career Present method of handling stress: 13. Number of hours of sleep per night? 14. What is your available time and frequency for exercise? What days: M T W Th F What times: am pm 15. Any special considerations or requests? Bus: Fax: Page 4 of 5
5 Client Agreement This contracts being entered into between Dynamic By Nature Ltd. (referred to as DBN ) and, (referred to as Client ), for services beginning on, and ending on. Fitness-based sessions will be performed times per week (month) and will cost $ plus taxes per week (month). The Client will be invoiced once a month and will pay by cheque or cash within one week of invoice. The Client s trainer will be. If cancellation is not received 24 hours in advance, the Client agrees to pay in full for the scheduled session. This contract may be terminated with seven (7) days written notice to the other party. I, the Client, am committed to making a positive change in my health through my participation in the monthly DBN program. I understand that certain elements of this program can be physically demanding, and that I may need to change various aspects of my lifestyle in order to realize the goals I have set in this program. I realize that DBN is responsible for providing the coaching I request. I am responsible for my own participation in this program, for my own physical and emotional well-being, and for the attainment of the goals I have established of this program. TOTAL RELEASE AND WAIVER OF LIABILITY As a condition of my enrollment, I accept full and complete responsibility for my own ability to healthfully participate in this program. I understand that participation and use of instruction, programs, activities, services, facilities, and equipment provided by DBN is potentially hazardous. I hereby release DBN, its directors, officers, agents, employees, trainers, management, representatives, their assigns, their heirs, executors, and administrators, and all others from any responsibility or liability for any injury, damage or any loss whatsoever, including those caused by their negligence. I have read and understood the above, and understand that it sets out the terms of engagement, and that it is also a total release, and waiver of liability. Client signature: By: Dynamic By Nature Ltd. Date: Date: Bus: Fax: Page 5 of 5
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