New Client Form

Transcription

New Client Form
BUSTAMOVE SCREENING FORM
Seniors
1 on 1
Groups
This is your personal screening form, to be completed prior to your first training sessioin with Bustamove Personal Training. All information
will be kept confidential. This information will be used for the evaluation of your health & readiness to begin our exercise program
PERSONAL DETAILS & LIFESTYLE PROFILE
Name:
Address:
Phone Numbers: Home:
Email Address:
Emergency Contact:
How did you hear about Bustamove?
. Date fo Birth:
. Postcode:
Mobile:
.
.
.
.
.
Phone:
.
.
PRE ACTIVITY QUESTIONAIRE
Do you experience or have experienced the following conditions?
Heart Attack
Pain/Tightness in Chest
High Blood Pressure
Rheumatic Fever
Palpitations
Epilepsy
Diabetes
Stroke
Arthritis
Major Surgery
Any Major Illness
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Depression
Anxiety
Pace Maker
High Cholesterol
Regular headaches/migraine
Asthma
Eating Disorder
Back Pain
Muscular or Skeletal Problems
Liver/Kidney Problems
Hernia
Pregnancy
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Please provide further details:
.
Are you taking any medication? If so, what?
.
Please highlight any body pains
Front
Back
Do you smoke? Yes / No
If yes, how many per day?
How much alcohol do you drink?
.
.
PERSONAL INFORMATION
Your occupation:
Do you consider your position at work to be:
O Sedentary O Moderately Active O Active
How many times per week to you wish to train?
Do you do any other exercise?
.
.
.
Please explain any injuries/conditions circled in the
diagram to the right:
.
A MINIMUM OF 24 HOURS NOTICE IS REQUIRED FOR CANCELLATIONS OR A FULL FEE WILL APPLY
I
have enrolled to participate in a program of physical activity, including but not limited to aerobic conditioning, weight
training and the use of various cardiovascular conditioning equipment offered by Bustamove.
I understand and am aware the strength, flexibility and aerobic exercise, including the use of equipment, is potentially hazardous activity. I aslo understand
that fitness activities involve risk of injury and even death, and that I am voluntarily participating in theses activities and using equipment and machinery with
knowledge of the dangers involved. I hearby agree to expressly assume and accept any and all risks of injury and or death.
In consideration of my participation in the exercise program at Bustamove, I hereby release Bustamove (its contract workers & directors), from any claims,
demands and causes of action arising from my participating in this exercise program.
SIGNATURE:
DATE:

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