Personal Training Health Screening Questionnaire

Personal Information

Today’s date: {sign_date}

Title: Dr. Mr. Mrs. Ms.

Name:  {name}   Birthdate: {dob}   Age:

Address: {address}

Email:

Phone:(home) {phone}

Phone:(work)  

Phone:(cell)  

Fax:  

Occupation:  

Gender: Male Female   Height:     Weight:   

Person to contact in case of emergency: {contact_name}

Tel: {contact_phone}

Physician’s Name:

Tel:

May I send a copy of your consultation to your physician &/or physical therapist?

Yes No

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 12months)

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)

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?  

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 1 2345

Personal/Emotional 1 2 3 4 5

 Mental/Career 1 2 3 4 5

12. 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:  Is pm 

15. Any special considerations or requests?

Date:  {sign_date}

Photo Release Form

I understand that the Women’s Health and Fitness Center may take photos and/or videos of  workout participants during program activities and events for use in promotional materials in  print, multimedia, or web form. Photos/videos will only be used for purposes related to the  Women’s Health and Fitness Center activities and their related partners. 

Please check the correct box below as to whether you do wish or do not wish to grant  permission to use your photos/videos taken during an activity. Additionally, please complete  the information below and sign this form in verification of your permission regarding the  Women’s Health and Fitness Center using your photos/videos. 

I DO grant permission for the use of my photo/video. 

I DO NOT grant permission for the use of my photo/video. 

Name:{name}

Guardian Name (if participant under 18) 

Email:  

Date: {sign_date}

Training Agreement

Name: {name}  Home Phone: {phone}  Work Phone:

Address: {address}

Email Address:  . Driver’s License:

Date of Birth: {dob}

Credit Card Authorization 

Card Holder Name:

Credit Card: MC VISA AMEX

CVC Exp:

Credit Card Number:

The undersigned authorizes WHFC to charge membership fees to the credit card account named above.   

Signature of card holder:       Date: {sign_date} 

1. Notice to purchaser do not sign this contract until you read it

2. Cancellation can only occur by midnight of the 3rd business day after you sign this contract. A written notice must be sent by certified mail stating your desire to cancel. Mail to 1208 1st Street East, Suite D Humble, Texas 77338. Under no circumstances will a refund be given. 

3. If WHFC goes out of business and does not provide facilities within 15 miles of the facility in which you are enrolled or if the Gym moves more than 15 miles from the facility in which you are enrolled, you many cancel this contract by certified mail. Mail your request to Mail to 1208 1st Street East, Suite D Humble, Texas 77338.

4. If you die or become totally or permanently disable after the date of this contract takes effect, you or your estate may cancel this contract and receive a partial refund of your unused membership fee by mailing a notice to the Gym stating your desire to cancel this contract. Proof of said disability or death must be mailed with request certified mail to 1208 1st Street, Suite D Humble, Texas 77338.

If TRAINING is terminated before the end of the duration of the contract there will be a $500.00 cancellation fee. Cancellation fee is to be paid in one lump sum. NO payment arrangements will be accepted. Members are obligated to the number of monthly dues specified in the agreement. 

THE ABOVE RULES AND REGULATIONS ARE INSTITUTED FOR THE GOOD OF ALL MEMBES AND ANY VIOLATION OF THE ABOVE RULE WILL RESULT IN MEMBERSHIP CANCELLATION AND WILL NOT RELIEVE MEMBER OF FINANCIAL RESPONSIBILITY OBLIGATIONS. ABSOLUTELY NO REFUNDS WILL BE GIVEN. 

MEMBER ACKNOWLEDGES THAT HE/SHE HAS READ AND RECEIVED A COMPLETE COPY OF THIS AGREEMENT

DATE:  {sign_date}. MEMBER {name}