Complete enrollment packet and schedule a time to meet with Louie Morphew.

Transcription

1 Fitness Intake Packet (Personal Training and Adaptive Fitness Clients) Please follow the step-by-step instructions listed below. If you have any questions or concerns, please Louie Morphew at Step 1: Complete enrollment packet and schedule a time to meet with Louie Morphew. Step 2: Meet with Louie to discuss exercise goals, health history, confirm appointment times and discuss any other pertinent information. Step 3: Obtain medical clearance from your physician if deemed necessary after your personal training / adaptive fitness intake meeting. Step 4: Wait patiently for medical clearance (if required) and also for your Personal Trainer to confirm your first training session. Step 5: Workout!

2 Name Date Sex Date of Birth Address Emergency Contact Physician Primary Phone Secondary Phone Emergency Contact Phone Physician Phone Campus Affiliation (Please circle all that apply) Student Staff* Faculty* Community Member* MSU Denver CU Denver CCD AHEC* Alumni* Student ID # (If applicable) Department or Major (if applicable) Please circle your preferred method of communication with your Personal Trainer: Text Call *Please note that faculty, staff, AHEC, alumni and community members must buy a membership sticker each semester.

3 Personal Training /Adaptive Fitness Program Please check the program for which you plan to enroll. Personal Training Small Group Personal Training Adaptive Fitness (Personal training for students, faculty and staff with disabilities) Health and Fitness Goals These questions will help us better understand your goals and your exercise history. Your program will take into account both your goals and how you perform on the fitness assessment. If you have questions regarding how to meet your goals please consult further with your trainer. Please indicate your fitness and wellness related goals: (check all that apply) Cardiovascular endurance Reduce Body Fat Weight Loss Stress Reduction Sleep Better Gain Strength Muscle Endurance Muscle Size Improve Balance Sport Specific Improve Appearance Gain Independence Improve Diet Other How will you know that you are succeeding? What barriers have stopped you from meeting these goals in the past? The personal trainers at Campus Recreation want to help you to achieve your goals and to become more physically fit. In order to do so there needs to be a high level of commitment from you. Please write down below two commitments you are willing to make during your participation in the program. For example, you might commit To eating 3 well balanced meals and 2 snacks each day of the week. When finished, please sign this form to signify your personal commitment. Commitment #1: Commitment #2 Signature:

4 Personal Training/ Adaptive Fitness Program Health and Fitness Goals Current Exercise Participation Have you been involved in an exercise program over the past month? (skip the next 2 questions if you have not been exercising) On average, how many times a week do you exercise? How long have you been on a regular exercise routine? (years) During a typical week what exercises do you participate in and for how long (please check all that apply and write in the number of minutes per week to the right)? Running Weight Training Biking Hiking Walking Golf Tennis Group Aerobics Swimming Skiing Other (please specify) Are there any exercises or physical activities that you don t like? Please list any activities that you are not currently participating in that you would like to add to your weekly routine.

5 Health and Fitness Goals Dietary Habits How many meals do you typically eat per day? How many 8 ounce glasses of water do you drink per day? Do you consume alcohol? If so, how many drinks do you have each week. Medications Please list any medications you are taking and the dosage level if known. Medication Dosage Please check any of the following that you have had or currently have: History (You may need medical clearance if you have marked any of the below issues) Cardiac Issues Diabetes Arthritis Abnormal EKG Thyroid Disease Anemia Stomach Problems Kidney Disease Hernia Transplants (please specify) Pregnancy Gout HIV/Aids Asthma or other lung disease Hepatitis Gastric Bypass Surgery Nerve Damage Stroke Epilepsy Surgery Chronic headaches or migraines Cancer Pulmonary Disorders

6 Health and Fitness Goals Symptoms (You may need medical clearance for any of these symptoms) Shortness of breath or unusual fatigue with usual daily activities Chest Pain Known heart murmur Chest discomfort with exercise Dizziness, fainting or blackouts Ankle edema Tachycardia (rapid heartbeat) Pain, discomfort in the chest, neck, jaw, arms, or other areas that may result from ischemia Joint or muscle pain (please specify) Ankle Low Back Other Knee Shoulder Hip Neck Burning or cramping in lower legs when walking a short distance Cardiovascular Risk Factors You are a man > 45 years You are a woman > 55 years Your blood cholesterol is > 200 mg/dl Your blood pressure is greater than 140/90 confirmed on at least two separate occasions Your LDL cholesterol is > 130 mg dl (if known) Your fasting glucose > 100 mg dl (if known) Your waist size is > 40 inches (males) or > 35 inches (females) You are physically inactive getting less than 30 minutes of physical activity on at least 3 days a week You are a current smoker. Please list the number of cigarette or cigars you smoke per day. You previously were a smoker. Please indicate when you quit smoking.

7 Health and Fitness Goals Please list any other medical issues you may have and any surgeries you have had in the past. When were you last seen by a physician? Reason: May we contact them? Yes No Has your physician advised against exercise? Yes No Do you use an assistance device(s)? Do you have any movement limitations? Is your movement limitation permanent? Yes No Unknown Are you currently receiving physical therapy? Yes No May we contact them? Yes No Has your therapist advised against exercise or specific exercises? Yes No NA Family History Please check any of the following that your mother, father, grandparents or siblings have had (please check all that apply): Heart Attack Diabetes Arthritis Stroke Heart Disease Asthma Hypertension Obesity Cancer Risk Stratification Results (Campus Recreation Staff Only Mark Below This Line) High Risk Moderate Risk Low Risk

8 Informed Consent Form The tests included in the fitness evaluation include the following areas: (1) muscular strength/muscular endurance, (2) body composition, (3) flexibility, (4) girth measurements, (5) cardiovascular endurance, (6) resting measurements (heart rate & blood pressure). The most physically demanding of the tests is the muscular strength, muscular endurance and cardiovascular endurance testing. Muscular strength is assessed using the bicep curl test and hand grip strength test. Muscular endurance is assessed through push-up and one minute crunch tests. The 3-minute step test which involves stepping up and down on a bench is used for testing cardiovascular endurance. To get an accurate account of your body composition you will need to wear shorts on the day of testing to allow the trainer access to your thigh area with skinfold calipers. The personal trainer will use a three site measurement that includes chest, abdomen and thigh for males and tricep, suprailiac and thigh for females. Muscle fatigue and failure may be experienced during any of these tests. Large increases in blood pressure may be present as a result of the bicep curl test. If the exerciser experiences any discomfort or is not tolerating the test well, it will be stopped. Complications during testing are rare but faintness and irregularities in heart function have been reported. Adaptive Fitness clients may have a modified fitness evaluation based on any limitations, current physical fitness level and experience with exercise. In signing this consent form, you acknowledge that you have read and understood the description of these tests and their complications. In addition, you state that any questions you have about these tests have been answered to your satisfaction. You are entering into these tests willfully and may withdraw at any time from any of the tests. A physician s examination is recommended for those men > 45 years of age and women > 55 years of age and also for those who have exercise restrictions. By signing below, you accept full responsibility for your own health and well-being and you acknowledge an understanding that no responsibility is assumed by the leaders of the program. Participant s name (please print clearly) Participant s signature Parent/Guardian signature (if needed) Campus Recreation employee signature Date:

9 Participation Agreement, Waiver and Release The undersigned realizes that it is a privilege to be a participant in the personal training / adaptive fitness program of Campus Recreation at Auraria and agrees to obey all rules and regulations governing the use of Campus Recreation at Auraria. This facility prohibits physical abuse, threats, intimidation, harassment, coercion, and /or other conduct which threatens or endangers the health or safety of any person or violates any campus rule or policy. The faculty and staff of Campus Recreation at Auraria, Intercollegiate Athletics, The Human Performance Sport and Leisure department at Metropolitan State University of Denver and the PER Events Center reserve the right to remove the undersigned from this facility who in their judgment violates campus rules or policies, misuses equipment, or commits any act detrimental to the best interests of the campus community. The undersigned may be subject to discipline under the various campus disciplinary codes, local ordinances, or state laws. Failure to comply with the request to leave the facility will result in notification of Auraria Public Safety (campus police), and subject the undersigned to arrest. The personal training / adaptive fitness fee will NOT be refunded to the undersigned if requested to leave the facility. The undersigned recognizes that participating in extracurricular activities such as the personal training program is voluntary. The undersigned understands that certain risks of injury are inherent in physical exercise and athletics and cannot be entirely avoided: the undersigned assumes such risks as a condition of his or her participation. In consideration of being permitted to use Auraria Recreation facilities and participate in the above mentioned program, the undersigned hereby: releases, discharges, and holds harmless Metropolitan State University of Denver, Auraria Higher Education Center, and their respective employees, agents, successors, and assigns from all claims, losses, damages or expenses because of personal or bodily injury incurred or caused by me during or in conjunction with the above mentioned program and facilities use. Participant s Name Participant s Signature Date

10 Terms and Conditions 1. Personal training sessions that are not cancelled at least 24 hours prior to the scheduled time will be forfeited. The only exception to this policy will be a medical emergency with documentation. Failure to give proper notice (24 hour notice) three or more times during the same semester, will require you to go to the end of our waitlist when signing up for additional sessions. 2. Each personal training package has an expiration date on the sessions. Any sessions that remain after the expiration date will be forfeited: 1 session: 1 month from date of purchase 5 sessions: 2 months from date of purchase 10 sessions: 3 months from date of purchase 15 sessions: 5 months from date of purchase 20 sessions: 6 months from date of purchase Exceptions to this policy include: Extended leave of absence (vacation with the consult of the trainer). A medical condition that prohibits physical activity associated with training, physician communication is preferred in this situation. 3. If you have unused sessions left and you are unable to complete the sessions due to health reasons, enrollment status or other extenuating circumstances you may get a refund for unused sessions minus a $15 processing fee. 4. All personal training sessions are non-transferable. All personal training sessions must be paid in full prior to scheduling your first session with the trainer. 5. If the client arrives more than 15 minutes late for a scheduled appointment, the trainer may leave the premise and the appointment will be forfeited. 6. Participants may be required to have medical clearance if deemed necessary by their health history questionnaire. Any changes in medical history after starting the personal training program may require medical clearance to continue. Please inform your trainer of any changes in your health status. 7. All participants that sign up in the small group personal training program must complete all sessions with their partner(s) being present. 8. All participants who register for a personal training session package will receive a free initial fitness assessment. 9. Personal training records will be kept for 5 years after your last appointment with the trainer. Personal training records will be purged after 5 years of inactivity. Name Signature Date