Personal Training Consultation Questionnaire

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityCounty

Postal / Eir code

Email*

Confirmation EmailBy entering your email address you agree to receive marketing emails

Gender*

MaleFemaleOther

Date of Birth*

MonthDayYear

Age*

years

Height

FT

Weight

KG

Occupation?

Whats the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)

Do you follow a regular working schedule, do you work days, afternoon or nights?

How often do you travel?

RarelyA few times a yearA few times a monthWeekly

Please list the physical activities that you participate in outside of the gym and outside of work.:

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

YesNo

Do you feel pain in your chest when you do physical activity?*

YesNo

In the past month, have you had chest pain when you were not doing physical activity?*

YesNo

Do you lose your balance because of dizziness or do you ever lose consciousness?*

YesNo

Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

YesNo

Is your doctor currently prescribing medication (for example, blood thinners) for your blood pressure or heart condition?*

YesNo

Do you know of any other reason why you should not do physical activity?*

YesNo

If you are on any medications, please list them.

What additional therapies are being undertaken for the given health problem(s)?

If you have any injuries, please list them or simply write no.*

What additional therapies are being undertaken for the given injury?

Are you experiencing any stresses or motivational problems?

YesNo

Has anyone of your immediate family developed heart disease before the age of 60?

YesNo

Do any diseases run in your family?

YesNo

Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo

if yes please list:

Are you a current cigarette smoker?

YesNo

Your current diet could be best characterized as:

Please rate your readiness for change.

	1	2	3	4	5

1 is Not ready, 5 is Very ready

Where do you train*

gymhomeBoth gym and home

Which of the following best fits in with your goals?

Why?

What is your goal with your training?

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train a week to reach your goal?

Are you currently excersising regulary (at least 3x per week)?

YesNo

Have you trained with a personal trainer before?

YesNo

If yes what kind of training did you do:

Why did you choose me as your trainer?

What are your expectations for me as your trainer?

Any other relevant information?

By checking yes I agree to have been truthful in my responses and if anything was to change that may affect my responses I will immediately update Summit Performance & Health*

Yes

This form is an important legal document. It explains the risks you are assuming by participation in an exercise program. It
is important that you read and understand it completely.

Waiver, Informed Consent, and Covenant Not to Sue
I have volunteered to participate in a personal training plan/program under the
direction of Summit Performance & Health (Paul Tighe), which will include, but may not be limited to, weight
and/or resistance training. In consideration of Summit Performance & Healths (Paul Tighe) agreement to instruct, assist, and train me, I do here and forever
release and discharge and hereby hold harmless Summit Performance & Health (Paul Tighe), and their respective agents, heirs, assigns, contractors, and
employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of
or connected with my participation in this or any exercise program including any injuries resulting there from. THIS
WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY
OCCUR AS A RESULT OF (1) EQUIPMENT THAT MAY MALFUNCTION OR BREAK (2) ANY SLIP, FALL,
DROPPING OF EQUIPMENT AND (3) OUR NEGLIGENT INSTRUCTION OR SUPERVISION.

Assumption of Risk
I recognise that exercise might be difficult and strenuous and that there
could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical
changes during exercise does exist. These changes include abnormal blood pressure; fainting; disorders in heartbeat; heart
attack; and, in rare instances, death.
I understand that as a result of my participation, I could suffer an injury or physical disorder that could result in my
becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life.

I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate.
I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM
AGAINST Summit Performance & Health (Paul Tighe), or OTHERS REFERRED TO IN THIS DOCUMENT FOR ANY NEGLIGENCE OR THAT
OF OUR EMPLOYEES, AGENTS, OR CONTRACTORS.

Signature

Waiver, Release and Assumption of Risk Form