CHW Client Services Request Form

Client Services Request Form
Name*

First NameLast Name
Sex:*
SXU Employee*

YesNo
Employee ID
Cougar Card ID number (7 digits, ex. 0123456)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Best Contact Number*
Please enter a valid phone number.
Trainer Preference*

MaleFemaleNo Preference
Please take a minute to fill out the Physical Activity Readiness Questionnaire (PAR-Q) below. The answers will ensure you are fit to train without seeking prior medical advice. Please read each question carefully and answer honestly – our primary aim is always HEALTH and performance.
1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?*

YesNo
Please give a short explanation:
2. Do you feel or suffer with pain in your chest during physical activity?*

YesNo
Please give a short explanation:
3. In the past month have you suffered with chest pain when not doing physical activity?*

YesNo
Please give a short explanation:
4. Do you suffer with dizziness or ever lose consciousness?*

YesNo
Please give a short explanation:
5. Do you have bone or joint problems that could be made worse in change of physical activity?*

YesNo
Please give a short explanation:
6. Are you currently taking medication for blood pressure or a heart condition?*

YesNo
Please list medications:
7. Do you know of any other reason as to why you should not do physical activity?*

YesNo
Please give a short explanation:
If you have answered YES to any of the above questions, please seek medical advice before taking part in any physical activity.
In signing this document, you have stated that you are fit and healthy to train.
Date*

MonthDayYear
Email
example@example.com
My Products
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Initial Wellness Evaluation The Center for Health and Wellness personal trainer will provide a comprehensive evaluation. The evaluation will include a movement screen, noninvasive anthropometrics, and fitness measurements for all fitness levels. This evaluation is a critical step in understanding your needs and how to create a proper program for you as the client.
$75.00 Quantity

Total

$0.00
Signature

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