Client Assessment Readiness Questionnaire

Transcription

1 Client Assessment Readiness Questionnaire The following questions will help determine your level of readiness for change, your motivation towards reaching your goals, and identifying obstacles to your success. Please answer each of the questions completely as these answers will lead to the development of the best possible fitness program for you. 1. Are you at some sort of health risk because of your current behaviors/style? If so, please describe. 2. How do you feel making lifestyle changes will improve your quality of life and decrease your risk of health-related disorders? 3. Are you seeking to make lifetime changes or achieving a short-term, temporary goal? 4. Are you willing to get personally involved in planning a lifestyle change program or are you looking for someone to develop the program for you? 5. Are you open to trying different approaches or do you have preferred methods, areas to avoid, etc? 6. Are successes in small increments a motivator for you? If so, please give an example of a small increment success. 7. Are you willing to set realistic goals and prepared to deal with possible setbacks? 8. Are you willing to make lifestyle changes or would you rather maintain your current lifestyle with slight modifications? 9. Compared to previous attempts, how motivated are you at this time to try to change your lifestyle (use a 1-5 scale; 1=not at all motivated, 5= extremely motivated). Considering all outside factors at this time in your life (stress at work, obligations, etc) to what extent can you tolerate the effort required to stick to a lifetime exercise and nutrition plan (use a 1-5 scale; 1= cannot tolerate at all, 5=can tolerate easily). 10. How confident are you that you can work regular exercise into your daily schedule starting tomorrow (use a 1-5 scale; 1=not at all confident, 5=extremely confident). 11. Indicate your busiest day of the week and your easiest day of the week. Busiest: Easiest: 12. Write down all the pain you associate with being in your present situation (e.g., none of my clothes fit ; I have no energy ; My blood pressure is too high ).

2 NAME: HOME ADDRESS: City State ZIP PHONE: (home) (cell) Emergency Contact: _ Phone: ADDRESS: AGE: DATE OF BIRTH: SEX: (M or F) HEIGHT: (in.) CURRENT WEIGHT: (lbs) DESIRED WEIGHT: (lbs) PRIMARY GOAL : Lose Weight Maintain Weight Gain Weight Tone Up MEDICAL HISTORY: Have you experienced any of the following? Y N Do you have or have had any Heart attack, coronary bypass or other coronary surgery? Y N Do you have or have had any chest discomfort (especially with exertion)? Y N Do you have or have had High blood pressure? Y N Do you have or have had any extra, skipped or rapid heart beats/palpitations? Y N Do you have or have had any heart murmurs, clicks, or unusual cardiac findings? Y N Do you have or have had any knee problems/surgeries? Y N Do you have or have had any surgery problems/surgeries? Y N Do you have or have had any ankle swelling? Y N Do you have or have had any Peripheral vascular disease? Y N Do you have limitations of movement? Y N Do you have or have had any unusual shortness of breath? Y N Do you have or have had any light headedness or fainting? Y N Do you have or have had any Pulmonary disease (e.g., asthma, emphysema, etc)? Y N Do you have or have had any abnormal blood lipids (cholesterol, triglycerides)? Y N Do you have or have had any Stroke? Y N Any recent illness, hospitalization or surgical procedure within the past 4 months? Y N Medications of any kind? (if yes, list all on back) Y N Do you have or have had any diabetes or other metabolic disorders? Y N Are you pregnant now? Y N Is there any reason your physician would object to your dieting? Y N Is there a history of heart disease in your family? Y N Is there any reason your physician would object to your exercising? Y N Are there any other medical problems you are experiencing not covered above, Explain? Signature of Parent (If Applibale)

3 WAIVER OF LIABILITY & RELEASE FORM Name Address (STREET) (CITY) (STATE) (ZIP) Phone of Birth Emergency Contact Relationship Phone Because physical exercise can be strenuous and subject to risk of serious injury, I urge you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity. You agree that by participating in physical exercise or training activities, you do so entirely at your own risk. Any recommendation for changes in diet including the use of food supplements, weight reduction and/or body building enhancement products are entirely your responsibility and you should consult a physician prior to undergoing any dietary or food supplement changes. You agree that you are voluntarily participating in these activities and assume all risks of injury, illness, or death. You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability. You expressly agree to release and discharge the trainer/instructor from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the trainer/instructor, or Unlimited Fitness Results, for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence. If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from. By signing this release, I acknowledge that I understand its content and that this release cannot be modified orally. I fully understand that I may injure myself as a result of my enrollment and subsequent participation in this program and I, _ hereby release Unlimited Fitness Results, Inc from liability now or in the future for conditions that I may obtain. These conditions may include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat prostration, injuries to knees, injuries to back, injuries to foot, or any other illness or soreness that may incur, including death. I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENT Signature of Parent (If Applicable)

4 Personal Fitness Training Program Informed Consent Agreement Program Objectives I understand that my physical fitness program is individually tailored to meet the goals and objectives agreed upon by my personal trainer and myself. I understand, however, that my personal trainer cannot guarantee that I will accomplish the goals that I establish. My program goals include (please initial all that apply): Cardiovascular improvement Improved muscular endurance Increased strength Improved flexibility Decreased body fat Weight loss Other (list) Boot Camp style training Description of the Exercise Program I understand that my exercise program will involve participation in a number of types of fitness activities. These activities will vary depending upon my established objectives, but will probably include: 1) aerobic activities including, but not limited to, the use of treadmills, stationary bicycles, step machines, rowing machines, and running track; 2) muscular endurance and strength building exercises including, but not limited to, the use of free weights, weight machines, calisthenics, and other exercise apparatus; 3) other activities selected by my personal trainer and agreed upon by me; and 4) selected physical fitness and body composition tests. Description of Potential Risks My personal trainer has explained that no exercise program is without inherent risks and that, regardless of the care taken by my personal trainer, he (or she) cannot guarantee my personal safety. For example, when one induces cardiovascular stress through activity, injuries can range from occasional minor injury (e.g., pulled muscles, muscle soreness) to infrequent serious injury (e.g., heart attack, stroke, or other cardiovascular accidents) to the very rare catastrophic incident (e.g., death, paralysis). Likewise, I know that engaging in muscular endurance, strength building, and other fitness activities occasionally results in minor injuries (e.g., bruises, musculo-skeletal strains and sprains), infrequently, more serious injuries (e.g., muscle tears, herniated disks, torn rotator cuffs), and very rarely, catastrophic injury (e.g., death, paralysis). I realize that when participating in any exercises or conditioning activity, there is always a possibility that minor injuries, major injuries, or catastrophic injury/death may occur. Description of Potential Benefits I understand that a regular exercise program has been shown to have definite benefits to general health and well-being. I know that some of the physiological benefits of a regular exercise program can include loss of weight, reduction of body fat, improvement of blood lipids, lowering of blood pressure, improvement in cardiovascular function, reduction in risk of heart disease, improved strength and muscular endurance, improved posture, and improved flexibility. I further understand that regular exercise can have psychological benefits, often improving one s outlook and feeling of well-being, as well as relieving tension and stress. Client Responsibilities I understand that it is my responsibility to: 1) fully disclose any health issues (including diabetes, heart problems, seizures, and asthma) or medications that are relevant to participation in a strenuous exercise program; 2) inform the trainer if there are activities with which I do not feel comfortable; 3) cease exercise and report promptly any unusual feelings (e.g., chest discomfort, nausea, difficulty breathing, apparent injury) during the exercise program; and 4) clear my participation with my physician.

5 Client Acknowledgements In agreeing to this exercise program, I, the client: acknowledge that my participation is completely voluntary. understand the potential physical risks involved in the exercise program and believe that the potential benefits outweigh those risks. give consent to certain physical touching that may be necessary to ensure proper technique and body alignment. understand that the achievement of health or fitness goals cannot be guaranteed. have had a voice in planning and approving the activities selected for my exercise program. have been able to ask questions regarding any concerns I might have, and have had those questions answered to my satisfaction. am in good physical condition, have no impairment which might prevent my participation in such activities, and have been advised to consult a physician prior to beginning this program have been advised to cease exercise immediately if I experience unusual discomfort and feel the need to stop. I have read and understand the above agreement. I have been made fully aware of and understand the potential risks involved in this physical fitness program. I hereby consent to those risks and am freely and voluntarily participating in this program. Finally, I am freely signing this agreement. Signature of Parent (If Applicable)

6 Commitment Agreement Between (CLIENT) and (TRAINER) It is agreed that (TRAINER) will contribute top notch education, motivation, and the blueprints for quick and safe fitness results for (CLIENT). In return (CLIENT) will contribute honest effort, time, and desire to achieve the following results (CLIENT GOALS HERE) It is agreed that only full and complete teamwork will achieve these results. It is also agreed that the CLIENT will commit to contribute maximum effort without excuse or procrastination. Furthermore it is agreed that the TRAINER will commit seeing the CLIENT to success. This constitutes the entire Commitment Agreement between CLIENT and TRAINER. This Agreement remains in force for a period of four weeks at which point CLIENT and TRAINER will reassess goals and recommit to a new goal and agreement. Agreed and Approved by: CLIENT/Soon To be Success Story : Agreed and Approved by: TRAINER :