MK27Fitness Consultation Questionnaire

  • Fitness Consultation Questionnaire

    MK27Fitness

  • About you

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is their any history of family illness?*
  • Do you suffer from diabetes, asthma, high or low blood pressure?*
  • Are you less that 6 week postnatal, pregnant or planning a pregnancy?
  • Are you a current cigarette smoker?

  • At the moment

  • How much sleep do you have on average?

  • The future

  • What do you want to achieve?*
  • I am happy for MK27Fitness to contact me by: (please tick as appropriate)*

  • PERSONAL TRAINER TERMS & CONDITIONS

    The following when signed will constitute the full agreement between the named personal trainer and client.

    The trainer will act as a personal trainer (PT) in the development of an exercise programme during the agreed sessions.

    In consideration of the service, the Client shall pay in advance according to the session rates charged by the personal trainer.

    All purchased sessions must be completed within 12 weeks from the first completed session.

    The Client understands that:

    Cancellation Policy: It is the responsibility of the client to ensure that the time and date booked are correct. To cancel a booked session the client must notify the PT in the first instance. If the PT in not contactable the Client should leave a message notifying the PT of the cancellation. Likewise the PT is responsible for notifying the Client of any cancellation. The Client may be charged for session missed as follows:

    • More than 24 hours notice: - no charge/ loss of session

    • Less than 24 hours notice: - full charge or reduction of 1 session from purchased block

    Late arrivals: The PT is only required to wait for 20 minutes past the agreed start time. After this the Trainer may leave the premises and the Client will forfeit the amount for the session. If the Client arrives within the 20 minutes, the PT will only complete the time left of the original session. No extra time will be given.

    If the PT is more than 10 minutes late on arrival to the session, the Client can have a full hour from the time that the PT arrives (if it is convenient), or the Client can have the remaining time of the session plus a free session.

    Declaration of understanding

    I, the Client, fully understand and agree to abide by the above rules and regulations. I clearly understand that the PT is not a medical doctor and therefore cannot diagnose or prescribe treatment for any form of injury, disease or any other medical condition. Before embarking on an exercise programme I must have completed the PAR-Q and resulting processes. I also understand that I should inform you of any other medical conditions that may not have been covered in the form and that I may be advised to visit my doctor before commencing the sessions.

    I acknowledge that I have either had a physical examination and have been given my doctors permissions to participate, or that i have decided to participate in the activity and/ or use the equipment and machinery without the approval of my doctor and do hearby assume all responsibility for my participation and activities. I release the PT who trains me from any liability for personal injury or other damage I may sustain whilst engaging in any exercise programme suggested by the PT.

    I, the Client, understand my participation in any assessments and future exercise is voluntary. Before commencement, all aspects of the programme will be fully explained to the client.

    I, the Client, am free to deny or withdraw their consent at any time.

    It is my, the Client's, full responsibility to inform the trainer of any changes to my physical and medical condition, or difficulties they perceive or experience.

    The client is requested to voice any concerns, reservations or doubts and to ask for clarification or an explanation. Questions regarding future procedures, risks or benefits are also encouraged.

    The client consents to being aware of their own health and physical condition. The client understands that participation in this programme and any fitness-testing procedures or assessments may be injurious to the client’s health. The client is voluntarily participating in an exercise and nutrition programme written by the trainer. In having this knowledge, the client thereby releases the trainer and the trainer’s representatives, agents, employees and successors from liability for accidental injury, illness or death which may occur as a result of participating in the said programme. I, the Client, hereby assumes all risks connected therewith and
    consents to participate in said programme.

    The trainer accepts no liability for any damage or loss to a client’s personal property brought into the premises and being used by the trainer.

    The trainer is not responsible for any closure of the premises used for personal training but will endeavour to find a suitable replacement with reasonable notice.

    The purchase of any course or product is deemed acceptance of these Terms & Conditions.

  • I AGREE TO THE ABOVE TERMS & CONDITIONS*

  • PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

    (PARQ)

    Before you begin exercising your instructor needs to know some information about you to ensure the exercises are safe and effective. If you are between 15-69 years of age this PAR Q checklist will assist you in making a decision about your state of health before you change or increase your physical activity behaviour. If you are over 69 years of age and not already participating in regular exercise it is advisable to check with your doctor before you begin.

     

  • Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
  • Do you have pains in your chest whilst performing physical activity?*
  • Have you had chest pain while not doing physical activity?*
  • Do you lose your balance because of dizziness or do you ever lose consciousness?*
  • Do you have a bone or joint problem (e.g., back, knee or hip) that could be made worse by a change in your physical activity?*
  • Is your doctor currently prescribing any medication for your blood pressure or heart condition?*
  • Do you suffer from high cholesterol?*
  • Have you had surgery recently?*
  • Is there a history of coronary disease in your immediate family?*
  • Do you have any chronic illnesses or physical limitations?*
  • Do you have any injuries, bone/joint or orthopedic problems (such as back, shoulder, knee etc) that affect your ability to exercise?*
  • Do you take any medication (prescription or non-prescription) that affects your ability to exercise?*
  • Do you know of any other reason why you should not participate in physical activity? If yes, please explain.*

  • If you answered:

    YES to one or more of the questions above you should consult your doctor to gain consent before participating in physical activity.


    NO to all the questions above it is considered reasonably safe for you to participate in regular physical activity. It is recommended that you start slowly – 20-30 minutes of low to moderate exercise, 3-5 times per week – and gradually build up from your current ability level.


    It is advisable to consult with a qualified fitness professional to help you develop a safe and effective physical activity plan to meet your fitness goals and health needs.


    I have read and understood the questions above and any questions I had have been answered to my satisfaction.


    I understand that I am voluntarily engaging in a level of exercise appropriate for my ability and that my participation involves a risk of injury.

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