About you

Full Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Date of Birth*

MonthDayYear

Emergency Contact Name*

First NameLast Name

Emergency Contact Number*

Please enter a valid phone number.

If you have any diagnosed health problems please list the condition(s).

If you are on any medications, please list them.

If you have any injuries, please list them.

Is their any history of family illness?*

YesNo

Please list:

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

YesNo

Please list:

Are you less that 6 week postnatal, pregnant or planning a pregnancy?

Less than 6 weeks post natalPregnantPlanning a pregnancyN/A

If you have any medical conditions or are on medication has your doctor cleared you to participate in fitness and exercise activities?*

Are you a current cigarette smoker?

YesNo

What is your daily consumption of glasses of water?

What is your daily consumption of glasses of fizzy drinks/ soda?

What is your daily consumption of cups of tea/ coffe?

What is your weekly consumption of alcohol (in units)?

At the moment

What do you do for a living?

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

How much sleep do you have on average?

4-6 hours6-8 hours8-10 hours10+ hours

How good do you think your nutrition is?

How would you rate your energy levels?

How would you rate your activity level?

How would you rate your stress levels?

The future

What do you want to achieve?*

What do you want to achieve from your consultation?*

Which of your goals is most important to you?*

I am happy for MK27Fitness to contact me by: (please tick as appropriate)*

EmailPostText/ Phone

I am happy for MK27Fitness to use my testimonial for marketing purposes:*

I am happy for MK27Fitness to use my photo for marketing purposes:*

I agree to MK27Fitness to send me updates on MK27Fitness products and promotions. I agree to them contacting me using the details provided and understand that these details will be added to the MK27Fitness database.*

I do not want MK27Fitness to send me any marketing materials. I understand that they will need to store my details for payments and for emergency contact details.*

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*

YesNo

I have completed this questionnaire to the best of my knowledge and ability.*

Yes

Signature*

Fitness Consultation Questionnaire

About you

At the moment

The future

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

(PARQ)

If you answered: