• Privacy & Confidentiality Statement

  • Client Form

  • Gender*
  • Date Of Birth*
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What's your goal?*
  • What's your goal?*
  • Would you like to include any of the following methods to help track your progress? (Please select all that apply) This is optional, but it can offer valuable insights into your journey.*
  • Where do you prefer to train on your own?*
  • Where do you prefer to train?*
  • Have you followed any fitness plans before?*
  • Have you followed any diets before?*

  • Pre-Exercise Screening Questionnaire

  • This questionnaire is designed to help assess an adult’s readiness for physical activity and identify potential risks prior to beginning an exercise program.The questions are informed by standard pre-exercise screening guidelines, including those outlined in the Adult Pre-Exercise Screening System (APSS).

    Important: This form is for informational purposes only and does not replace professional medical advice. Participants should consult a qualified healthcare professional before starting or changing any exercise program.

  • Q1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?*
  • Q2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?*
  • Q3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*
  • Q4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*
  • Q5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose)in the last 3 months?*
  • Q6. Do you have any other conditions that may require special consideration for you to exercise?*

  • IF YOU ANSWERED ‘YES’ to any of the 6 questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.

    IF YOU ANSWERED ‘NO’ to all of the 6 questions, please proceed to question 7 and calculate your typical weighted physical activity/exercise per week.

    Once you have completed and submitted this form, if your responses indicate that a referral may be appropriate, I can assist you through the referral process. I will help connect you with a suitable allied health professional or medical practitioner to ensure you can safely undertake exercise.

  • Q7. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities.

  • Rows

  • If your total is less than 150 minutes per week then light to moderate intensity exercise is recommended. Increase your volume and intensity slowly.

    • If your total is more than or equal to 150 minutes per week then continue with your current physical activity/exercise intensity levels.

    • It is advised that you discuss any progression (volume, intensity, duration, modality) with an exercise professional to optimise your results.

  • Q9. Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months?*

  • Q10. Body composition

    Any of the below increases the risk of chronic diseases:

    BMI ≥ 30 kg/m2

    Waist > 94 cm male or > 80 cm female

  • Q11. Have you been told that you have high blood pressure?*

  • Either of the below increases the risk of heart disease:

    Systolic blood pressure ≥ 140 mmHg

    Diastolic blood pressure ≥ 90 mmHg

  • Are you taking any medication for this condition?*
  • Q12. Have you been told that you have high cholesterol/blood lipids?*

  • Any of the below increases the risk of heart disease:

    Total cholesterol ≥ 5.2 mmol/L

    HDL < 1.0 mmol/L

    LDL ≥ 3.4 mmol/L

    Triglycerides ≥ 1.7 mmol/L

  • Are you taking any medication for this condition?*
  • Q13. Have you been told that you have high blood sugar(glucose)?*

  • Fasting blood sugar (glucose) ≥ 5.5 mmol/L increases the risk of diabetes.

  • Are you taking any medication for this condition?*
  • Q14. Are you currently taking prescribed medication(s)for any condition(s)? These are additional to those already provided.*

  • Taking medication indicates a medically diagnosed problem. Judgment is

    required when taking medication information into account for determining

    appropriate exercise prescription because it is common for clients to list

    ‘medications’ that include contraceptive pills, vitamin supplements and other

    non-pharmaceutical tablets. Exercise professionals are not expected to have

    an exhaustive understanding of medications. Therefore, it may be important

    to use common language to describe what medical conditions the drugs are

    prescribed for.

  • Q15. Have you spent time in hospital (including day admission) for any condition/illness/injury during the last 12 months?*

  • There are positive relationships between illness rates and death versus the

    number and length of hospital admissions in the previous 12 months. This

    includes admissions for heart disease, lung disease (e.g., Chronic Obstructive

    Pulmonary Disease (COPD) and asthma), dementia, hip fractures, infectious

    episodes and inflammatory bowel disease. Admissions are also correlated to

    ‘poor health’ status and negative health behaviours such as smoking, alcohol

    consumption and poor diet patterns.

  • Q16. Are you pregnant or have you given birth within the last 12 months?*

  • During pregnancy and after recent childbirth are times to be more cautious

    with exercise. Appropriate exercise prescription results in improved health

    to mother and baby. However, joints gradually loosen to prepare for birth

    and may lead to an increased risk of injury especially in the pelvic joints.

    Activities involving jumping, frequent changes of direction and excessive

    stretching should be avoided, as should jerky ballistic movements.

    Guidelines/fact sheets can be found here: 1) www.exerciseismedicine.com.au

    2) www.fitness.org.au/Pre-and-Post-Natal-Exercise-Guidelines

  • Q17. Do you have any diagnosed muscle, bone, tendon,ligament or joint problems that you have been told could be made worse by participating in exercise?*

  • Almost everyone has experienced some level of soreness following

    unaccustomed exercise or activity but this is not really what this question is

    designed to identify. Soreness due to unaccustomed activity is not the same

    as pain in the joint, muscle or bone. Pain is more extreme and may represent

    an injury, serious inflammatory episode or infection. If it is an acute injury

    then it is possible that further medical guidance may be required.

  • Date*
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  • Client Consent for Collection and Storage of Personal and Health Information

    By signing this agreement, I consent to the collection, use, and secure storage of my personal and health-related information as part of the at-home personal training and online coaching services provided by DLVR.

  • This includes data I provide through:

     

    • Client Form
    • Personal information (e.g., name, contact details, date of birth, goals, lifestyle details)
    • Pre-Exercise Screening Questionnaire
    • Baseline and ongoing progress data, including:
    • Body weight
    • Body circumference measurements
    • Progress pictures
    • Functional movement assessments
    • Any other relevant information I choose to provide

     

    I understand that this information is collected solely to support the design and delivery of personalised program, exercise, and general nutrition guidance, and for monitoring my progress over time.

     

    I acknowledge that:

     

    • My data will be stored securely (digitally and/or physically) and only accessed by my trainer/coach and DLVR.
    • My information will not be shared with third parties without my explicit permission.
    • I have the right to request access to, correction of, or deletion of my data at any time.
    • I may withdraw my consent at any time by providing written notice.
    • My data will be retained securely for as long as I remain an active client and, after our coaching relationship ends, for the period required by law or professional guidelines.

     

    By signing below, I confirm that I understand and agree to the collection, storage, and use of my personal and health-related information as outlined above.

  • Date
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