Adam Russell PT - Medical Questionnaire & Consent Form

Medical Questionnaire & Consent Form
Hello there!

Thank you so much for choosing me to help you and be a part of your fitness journey.

We are just one step away from starting to increase and/or diversify your fitness and activity levels. Being more active is very safe, however, some people should check with their doctor before they undertake a physical activity.

Please complete this form before your first personal training session so I can design a safe and effective programme for you. All information provided will be kept confidential and stored in accordance with applicable data protection legislation.

See you soon,

Adam
Part A: About you

Please complete with your personal, contact and emergency contact information:
Name*

First NameLast Name
DOB*

DayMonthYear
DD/MM/YYYY
Email*
example@example.com
Address*

Street Address

Street Address Line 2

Town/CityCounty

Postcode
Telephone Number*

Country CodePhone Number
Emergency Contact*

First NameLast Name
Emergency Contact Telephone Number*

Country CodePhone Number
Name of GP / Doctor*

First NameLast Name
GP / Doctor Telephone Number*

Country CodePhone Number

Part B: Medical Questionnaire

Please answer each question honestly and to the best of your knowledge. Tick the appropriate box for each question. If you answer "Yes" to any question, please provide details in the space provided.
1. Has a doctor ever told you that you have a heart condition, or that you should only undertake physical activity recommended by a doctor?*
Details
2. Do you experience chest pain, pressure or tightness during physical activity or at rest?*
Details
3. Have you ever lost consciousness, experienced dizziness or lost your balance, or have any condition which might predispose you to this? *
Details
4. Do you have high or low blood pressure, or are you taking medication to control your blood pressure?*
Details
5. Have you been diagnosed with diabetes (Type 1 or Type 2)?*
Details
6. Do you have asthma, epilepsy or any other condition that may affect your ability to exercise safely?*
Details
7. Do you have any bone, joint or muscular condition (including arthritis) that could be made worse by physical activity? *
Details
8. Have you suffered any injury in the last twelve months (including sprains, fractures, dislocations or surgery)? *
Details
9. Are you currently taking any medication, whether prescribed or over-the-counter? *
Details
10. Are you, or could you be, pregnant? *
11. Is there any other medical condition, illness, allergy or physical limitation that your trainer should be aware of? *
Details
If you answered YES to one or more questions:

It might be advisable to discuss with your doctor before participating in an exercise programme. Talk to your doctor about the kinds of acivities you wish to participate in and follow their advice.

PLEASE NOTE:
- You should delay becoming much more active, if you are not feeling well due to a temporary illness (e.g. cold or fever) and wait until you feel better.
- If your health changes so that you can then answer YES to any of the above questions, tell your fitness or health professional and consult your doctor.

Part C: Your Current Fitness Level

Please answer each question honestly and to the best of your knowledge. Tick the appropriate box for each question. If you answer "Yes" to any question, please provide details in the space provided.
12. How would you describe your current level of physical activity?*
13. Have you participated in personal training or a structured exercise programme before?*
Details
14. Do you have any specific fitness goals you would like to discuss with your trainer?*
Details

Part D: Your Obligations

By signing this form, you agree to the following obligations. Please read each statement carefully and click Yes to confirm your understanding and agreement.
15. I confirm that the information I have provided in this form is true, accurate and complete to the best of my knowledge. I understand that my trainer will rely on this information when designing my programme and that providing inaccurate or incomplete information may increase the risk of injury.*
16. I will inform my trainer immediately if my medical circumstances, medication or health status change at any time after I have completed this form.*
17. I will follow my trainer's instructions and guidance during all training sessions, including instructions relating to technique, use of equipment, warm-up and cool-down procedures and rest periods. However, if I do not want to participate in or continue with any exercise, or follow any instruction for any reason, I will tell my trainer.*
18. I understand that I must stop exercising immediately and inform my trainer at once if I experience any pain, discomfort, dizziness, faintness, nausea, shortness of breath, chest tightness or any other unusual symptom during a session.*
19. I will not attend a training session if I am feeling unwell, have consumed alcohol or have taken any substance that may impair my ability to exercise safely, unless I have discussed the matter with my trainer beforehand and the trainer has agreed that it is safe to proceed.*
20. I will wear appropriate clothing and footwear for each session and will use all equipment in the manner instructed by my trainer.*

Part E — Trainer's Commitment to Your Safety
21. Your trainer considers the safety and wellbeing of all customers to be paramount. Your trainer will at all times exercise reasonable care and skill in designing and supervising your training programme. Your trainer will take into account the medical and fitness information you provide in this form when planning your sessions, and will adapt exercises where reasonably necessary to reduce the risk of injury.

22. Your trainer holds appropriate professional qualifications and insurance, and undertakes to maintain those qualifications and insurance cover throughout the period during which sessions are provided to you.
Part F — Informed Consent to Risk

Please read each statement carefully and click Yes to confirm your understanding and agreement.
23. I understand that all physical exercise carries an inherent risk of injury. Even where a programme is properly designed and supervised with reasonable care and skill, there remains a risk that I may experience muscle soreness, strains, sprains, joint injury, cardiovascular events or other physical harm.*
24. I confirm that I have had the opportunity to ask my trainer any questions about the nature and demands of the training sessions, and I am satisfied with the answers I have received. If I have more questions during training sessions, I will ask the trainer and only continue if I am satisfied with the answers.*
25. I consent to participate in personal training sessions with full knowledge and acceptance of the inherent risks involved.*
Part G — Limitation of Liability

Please read each statement carefully and click Yes to confirm your understanding and agreement.
26. To the fullest extent permitted by law, I agree that my trainer (and any company, partnership or business through which the trainer operates) shall not be liable for any loss, damage or injury I may suffer in connection with my participation in training sessions, except where for injury caused by the trainer's negligence.*
27. Nothing in this form excludes or limits the trainer's liability for death or personal injury caused by the trainer's negligence, or for any other liability that cannot lawfully be excluded or limited.*
28. I acknowledge that this limitation of liability has been drawn to my attention, that I have read and understood it, and that I have had the opportunity to take independent legal advice before signing this form.*
Part H — Declaration and Signature
I confirm that I have read and understood this form. I have answered all questions honestly. I consent to participate in personal training sessions on the terms set out above.
Signature*
Print Name
Date*

DayMonthYear
Date
Should be Empty:

Medical Questionnaire & Consent Form

Part A: About you

Part B: Medical Questionnaire

Part C: Your Current Fitness Level

Part D: Your Obligations

Part E — Trainer's Commitment to Your Safety

Part F — Informed Consent to Risk

Part G — Limitation of Liability

Part H — Declaration and Signature

I confirm that I have read and understood this form. I have answered all questions honestly. I consent to participate in personal training sessions on the terms set out above.