Personal Training Client Information Pack PERSONAL DETAILS Please answer all questions below. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country DOB * Email * Mobile * LIFESTYLE QUESTIONNAIRE Please complete the following section about your current lifestyle. How would you rate your overall health and lifestyle ( 1 - Unhealthy to 10 - Healthy)? 1 - Unhealthy 2 3 4 5 6 7 8 9 10 - Healthy How would you rate your overall nutrition ( 1 - Unhealthy to 10 - Healthy)? 1 - Unhealthy 2 3 4 5 6 7 8 9 10 - Healthy How would you rate your activity level (this is all the activity you may do during the week such as walking, gardening etc., as opposed to formal exercise such as swimming or going to a class ( 1 - Inactive to 10 - Very active)? 1 - Inactive 2 3 4 5 6 7 8 9 10 - Very active Do you smoke or use e-cigarettes? Yes No Approximately how many units of alcohol would you consume in an average week (1 Unit = 1/2 pint of medium strength beer or a small glass of wine)? What exercise do you currently do (please don't worry if the answer is none!)? What do you think are the main benefits of exercise to you? Imagine you are seeing yourself in three months' time. How would you like to feel? What changes would you make? This can include physical goals such as weight loss or increasing strength but we'd also like you to think beyond this - would you like to feel less tired or more body confident? Try to think of 3 key changes you'd like to make. Physical Activity Readiness Questionnaire Being more active is very safe for most people. However some people should check with their doctors before they start becoming much more physically active. It is important that you complete this PAR-Q so that we know you are safe to exercise. Make sure that you read all questions carefully and answer honestly. Has your doctor ever said that you have a heart condition and recommended only medically supervised activity? Yes No Do you have chest pain brought on by physical activity? Yes No Have you developed chest pain in the last month? Yes No Do you tend to lose consciousness or fall over as a result of dizziness? Yes No Do you have a bone or joint problem that could be aggravated by the proposed physical activity? Yes No Are you currently, or have you been pregnant in the last 6 months? Yes No Have you had an operation in the last 6 weeks? Yes No Are you on any medication (please state below)? Do you have any other medical conditions/injuries/strains? Please state below. Are you aware, through your own experience or from a doctor's advice, of any other physical reason, why you should not exercise without medical supervision? Yes No If you have answered NO honestly to all questions above, you can be reasonably sure you are safe to exercise. If you have answered YES to one or more of the questions, talk to your personal trainer and ensure they are aware of these. Your personal trainer may restrict or modify your physical involvement in an exercise or activity. Depending on the severity of these positive answers, your personal trainer may ask you to refrain from an activity altogether before seeking medical advice. If this is the case you will be required to tell your GP or other relevant practitioner about the questions to which you answered positively, then approval to exercise will need to be obtained before full physical commencement of your sessions. Note any concerns below. If you have answered YES to any of the questions above, I confirm that I have sought advice from a medical professional who has approved me to exercise. Yes No In an emergency please contact: Name, relation and phone number I confirm that all information given is accurate to the best of my knowledge and that all exercise is done at my own risk throughout the duration of my personal training sessions. I confirm that I will advise CLC Fitness immediately upon becoming aware of any new medical conditions or should any circumstance arise whereby I would answer positively to any of the statements above. Please print name and date Informed Consent for Exercise Prescription Please complete the below. Programme objectives and procedures I understand that the purpose of personal training is to provide safe and individualised exercise to improve health and fitness. Exercises may include: - Cardiovascular activities - walking or jogging, rowing, upright or recumbent cycling, stair climbing and other such activities in outdoor and indoor environments - Resistance training activities using resistance machines, free weights, resistance bands or circuit training to improve muscular strength or endurance - Core and flexibility exercises to improve core stability and movement around the joints and range of motion I understand Potential risks The exercise programme is designed to place a gradually increasing workload on the cardiovascular and muscular systems and thereby improve their function. The reaction of the cardiovascular and muscular system to such exercise cannot always be predicted with complete accuracy. There is a risk of certain changes that might occur during or following the exercise. These changes could relate to blood pressure or heart rate. I understand Potential benefits I understand that a programme of regular exercise has been shown to be beneficial. Some of these benefits include: - A decrease in risk of heart disease - A decrease in body fat - Improved blood pressure - Improvement in psychological function - Improvement in aerobic fitness I understand Consent The personal training programme has been explained to me and my questions regarding the programme have been answered to my satisfaction. I understand that I am free to withdraw at any time. The information obtained will be treated as private and confidential. I understand Client signature Date MM DD YYYY Thank you!
