Personal Training Intake Form 2020 Intake form for Personal Training Clients Step 1 of 12 8% Physical Activity Readiness (PAR-Q)If you haven't been active recently, or are looking to add a new or more intense exercise to your current routine, the physical activity readiness questionnaire (PAR-Q) can help you decide if you are ready to exercise safely, or if you might need a trip to your physician to make sure you don't push beyond your own limit. Please mark the conditions you are experiencing or have in the past.* Your doctor has said that you have a heart condition and you should only do exercise recommended by a doctor You feel pain in your chest when you do physical activity You have had chest pain in the last month when you did physical activity. You lose your balance because of dizziness or you have lost consciousness. You have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity Your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition you know of any other reason why you should not do physical activity none of the above Clearance to workout* I have been cleared by doctor to begin exercise or do not have any of the conditions above.*NOTE: If you answered “yes” to one or more conditions above, please speak with your doctor by phone or in-person BEFORE you become more physically active or BEFORE you begin personal training and fitness testing. Please tell your doctor which questions you answered “yes” to and discuss possible exercise restrictions. Your safety when becoming more physically active is our main concern. IF YOU ARE PREGNANT OR YOUR HEALTH CHANGES PRIOR TO EXERCISING SO THAT YOU ANSWER “YES” TO ANY OF THE ABOVE QUESTIONS, WE STRONGLY RECOMMEND YOU SPEAK TO YOUR DOCTOR BEFORE MEETING WITH A BODY FIRST PERSONAL TRAINER! Contact InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Secondary Phone#*Date of Birth* Month Day Year Are you (the client) over the age of 18* YES NO If the client is 14 years or younger or special needs please contact Body First so we can make the appropriate accommodations All minors age 17 and younger are required to have parent consentConsent for personal training for a minor* Consent for personal training for a minorI hereby authorize Body First to provide personal training services for my minor child or dependent. Parent/Guardian Name First Last Emergency Contact* Emergancy Contact Phone #*EMAILBody First utilizes your email to send email appointment notifications, email reminders, and to contact you when we are unable to contact by other means. Please choose to OPT-IN if you want to receive news, updates, and specials from Body First. Email* EMAIL OPT-IN: Body First Wellness I would like to receive email wellness news and updates from Body First.EMAIL OPT-IN: Body First Strong I would like to receive fitness specific news and updates from Body First.EMAIL OPT-IN: Body First Tennis I would like to receive tennis specific news and updates from Body First. You and Body FirstAre you currently a Body First Client or Member?* Yes No Please mark all services or offerings you have utlized from Body First. Body First Membership Massage Therapy Personal Training Tennis Group Fitness Yoga Fitness Facilities Tennis Courts Other Body First services or offerings you have utlized: You and FitnessWhat made you decide to personal training*Have you trained with a personal trainer before? Yes No What are some of you favorite phycsical activities*HiddenOn a scale of 1 to 10 how passionate are you about working out??* 1= I cannot seem to ever make myself workout 2=have to force myself to workout, even then I hate it. 3=I don't despise working out but I don't quite enjoy it. 4=Sometimes I kinda enjoy working out but I do not do it often 5=I workout occasionally and I don't hate it when I do 6=I feel better and enjoy it when I workout but often "don't have the time" 7=I like working out and do it somewhat consistently. But sometimes I fall of the fitness wagon. 8=I look forward to my workouts and am consistent with them. 9=I hardly ever miss a workout but have a good balance between fitness and the rest of my life. 10=I never miss a workout!!! I live for fitness! Sometimes I workout 2-3 times per day Are you currently involved in an exercise regimen? Yes No What exercises are you currently doing your exercise regimen?What do you feel is currently missing from your current exercise regimen? Your GoalsIn order to increase the chances of reaching your goals and feeling succesful, we strive to ensure you goals are "SMART" S=Specific M=Measurable A=Attainable R=Reward-based (attach a reward to each goal) T=Time (set specific dates for goalsWhat Goals can we help you achieve? Select All Improve cardiovasuclar health Develop Muscle Tone Reduce Stress Rehabilitate an Injury Provide accountability Start an exercise program Desing a more advanced program Sports Specific Training Motivation Fun Training for an event Lose Body Fat Physical Fitness Test Mark all that applyTell us about your health related goalsLower blood pressure, improve cardiovascular health, etcIf you have any specific goals of related to performance let us know.faster 10K, bench press max, train for military fitness tests etc.Tell us if wanting to change your body compisitionWeight Loss, build muscle, etcWhat time period are you hoping to reach you goals?How important is it that you reach these goals? Not important Semi-Important Very Important What do you think the most important thing a trainer can do to help you achieve your goals?List what you may feel are obstacles or potential acitons, behaviors or activites that could impede you progess towards accomplishing your goals Lifestyle RelatedYour lifestyle impacts your health and also can be a determining factor in your success in regard to your personal fitness. At Body First, we strive to provide evidence-based training and guide you in ways to make your fitness journey a successful one. Choose those of the following best describe you. Retired Work Full Time Work Part Time Work from Home Stay at home parent Full-Time Student Part Time student None of the above What is your occupation?* What type of duties do you do at work?Computer work, heaving lifting, lots of driving, on you feet all day etc. What best describes your job? Sedentary Active Physically Demanding How many hours do you normally sleep per night? 3 or less Hours 4-5 Hours 6 Hours 7 Hours 8 Hours 9 Hours 10 or more Hours How would you rate the overall quality of your sleep in the last 7 days.. 0=Terrible 1= Extremely Poor 2= Very Poor 3= Poor 4= Somewhat Fair 5= Almost Fair 6= Fair 7= Somewhat Good 8= Good 9= Extremely Good 10= Excellent Do you smoke or vape? Yes No How much do you smoke or vape? 3-5 times/day, 1 time per day, weekends only, less than once a month, etc.Do you drink alcohol regularly? Yes No If you do drink regularly which best describes your drinking habits. Less than 3-6 drinks per week 7 or more drinks per week 1-2 Drinks per day 3 or more drinks per day Drink only with dinner Drink only weekends How many times on average to you eat fast food? Every day Once a week 2 to 3 times a week Once a month 2 to 3 times a month Less than once a month Never On a scale of 1 to 10 What is your stress level? 1= Very Mild Stress: Everything is a-ok! There is absolutely nothing wrong. Your probably cuddling spend your days cuddling a fluffy kitten! 2=Mild Stress: You are a bit frustrated or disappointed from time to time but are easily distracted and cheered up with a little effort 3= Somewhat Mild Stress: Things are bothering you, but you are comping. You might get overtired or hungry. This the emotional equivalent of a mild headache. 4=Very Moderate Stress: You may have a bad day (or a few bad days). You have the skills to get through it, like using self-care strategies or being gentle with yourself. 5=Stressed: The majority of days are stress filled and you are having difficulty relaxing and beginning to have trouble coping. 6= Definitely Stressed out: Your mental health is starting to impact your everyday life. Easy things might seem a little more difficult. 7= slightly Severe Stress: You can not do things the way you usually do them. Impulsive and compulsive thoughts may be hard to cope with. 8= You are avoiding things that make you more distressed, but that will make it wors. You should probably talk to your doctor. 9=Sever Stress: You can no longer hide your struggles anymore. You may have issues sleeping, eating, having fun, socializing, and work/study. Your mental health is affecting almost all parts of your life. 10= The worst mental and emotional distress possible. You can no longer care for yourself. You can not imagine things getting any worse. You seek help immediately. Health HistoryThough we are not required to by law, it is the intention of Body First to ensure the confidentiality and integrity of protected health information of both clients, members, and employees as required by HIPAA, professional ethics, licensure requirements, and any other legal requirements. At this time our website has a SSL Certificate, is PCI compliant, and have we enacted numerous protocols to protect your data and we do not store any personal health information in our database. At this time we have taken the numerous steps to ensure your information is safe and secure we are still working integrating our website to be HIPAA compliant. If you do not wish to answer any of the following questions online, we will collect this information at the time of your appointment. Existing Conditons* Unexplained weight loss or gain Chronic fatigue Change in appetite Cancer Heart attack Rapid or irregular heartbeats High blood pressure Stroke High blood cholesterol High blood triglycerides Diabetes Hypoglycemia/low blood sugar Asthma Unexplained shortness of breath during exercise Any injury related to physical activity Chronic joint or muscle pain Back pain Arthritis or a rheumatic condition Bone, joint, or muscular injury Surgical procedures Thyroid disease Epilepsy Eating disorder Persistent headache Bursitis None of the Above Please mark all conditions that applyAdditional information we should be awre of for the the existing conditions above that you marked. We STRONGLY RECOMMEND that if you marked any existing condtions above that you consult with your doctor before beginning any exercise program.Please explain the reason for your last doctor's visit (provide date you remember)Are you currently on Aspirin Therapy or taking any other blood thinners? Yes No Are you currently on any medications that could lower your blood pressure. Yes No Are you on any additional medications we should be aware of? If so what?Please list any know allergies (enviromental, medications, food, etc.)List any additonal medical concerns/condtiona that might limit your ability to participate in physical activity. (pregnancy, disability, injuries, etc.) Devoloping your fitness programHelp us provide you with a positive personal training experience. Please take the time to let us know what you are starting and what you would like to achieve.What have you been doing for fitness for the 30-60 days.What were you doing at the time to be in the best shape of you life? and when was that?What is currently missing from your routine? TRAINING PREFERENCESHave you trained with personal trainer before?* Yes No If yes, How often did you train?* 2 times per week, once a week, every other week, monthly, etc. List any additional conditons not listed Please explain of the conditions listed above. Your Agreement to ServicesPlease take a moment to read and agree the following statements regarding your treatment. By checking the boxes your are hereby affirming that you have read, fully understand and therefore consent to participating with Body First in programs and services within the framework stated below and in Body First's Privacy PolicyPrivacy Policy* I agree to the privacy policy.*Body First Policy Privacy Scheduling and Cancellation Policies* I agree to the Scheduling and Cancellation Policies.*Body First Cancellation and Scheduling Policies Personal Training for exercise and guidance.* Personal Training for wellness*I understand that the personal training services I receive are provided for the purpose of exercise instruction and guidance. Client Health Warranty* Client Health Warranty*I am not aware of any disability, impairment, or ailment preventing me from participating in personal training. I affirm that I have stated all my known medical conditions and injuries and answered all questions honestly. I agree to keep the personal traineres updated as to any changes in my health profile, and understand that there shall not be liability on the massage therapist’s part should I forget to do so. Furthermore I recognize that personal training may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities. I hereby affirm that I am in good physical condition and do not suffer from any know disability or condition, which would prevent or limit my participation in this exercise program. Personal Trainer role in client wellness.* Perosonal Trainer role in client wellness.*I understand that personal trainers are not qualified to diagnose or prescribe for disease conditions and that nothing said, done, performed, typed, printed or produced is intended or meant to diagnose, prescribe, treat a disease or takes the place of a licensed physician, chiropractor, registered dietitian or other qualified health professional. I understand that body maintenance assessments and suggestions are intended only for the support of optimal health and do not involve diagnosing, prognosticating or prescribing any remedies for the treatment of disease conditions.Client's Responsibility for their wellness* Client's Responsibility for their wellness*I understand that I accept total responsibility for my own health care and maintenance and that I should seek treatment from a physician, chiropractor, registered dietitian or other qualified medical specialist for any medical conditions that I am aware of.Trainer or coach's right to refuse service.* Trainer or coach's right to refuse service.*I understand that the trainer or coach may choose to end any session if they believe continueing could be detrimental to the client, the client is under the influence of drugs or alcohol, or the client exhibits any inappropriate behavior towards the trainer or coach. Client's Right to manage their personal training session* Client's Right to manage their personal training session*If I experience any pain or discomfort it is my responsibility for my own health, physical well being, and maintenance to inform the trainer/coach so they can adjust the program/session and help avoid injury. Release of liability Release of LiabilityIn consideration of my participation in this program, I hereby release Body First LLC and/or Body First Staff from any claims, demands, and causes of action as a result of my voluntary participation and enrollment of the provided personal training services and/or exercise classes. I fully understand that I may injure myself as a result of my enrollment and subsequent participation in this program, and I hereby release Body First or their employees, staff, or subcontractors from any 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 I may incur, including death. Consent of services of Minor Minors 14 and under and special needs clients: – Please inform Body First if the minor child is under age 15 so we can make accommodations for the parent/guardian to accompany the child. Updates to Policies in regards to COVID-19* I understand there are changes to Body First operations and policies relating to COVID-19 and Body First reserves the right to change their policies as time this situation progresses.*As Body First re-opens Body First, we have updated many of our operating procedures and policies to reflect the changes we have made in light of the COVID-19 Pandemic.https://bodyfirst.com/update-to-body-first-operations-and-policies-covid-19/CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ
