Small Group Training
New Client Information
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Best Phone Number to Reach You
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about AbbeySnell Fitness?
Personal History
Do you currently exercise regularly?
Has it been over a year since you have exercised?
Have you been hospitalized in the last 5 years? If yes, what is the reason?
Do you have high blood pressure? If yes, what is it?
Are you currently on any medications (for treatment of the above issues OR a separate issue)? If yes, what? Do your medications cause any side effects?
If you are on ANY medication for the above medical conditions a doctors note is REQUIRED before any training or nutrition program can begin. Please initial in agreement. *
Do you smoke?
Do you have any physical limitations that may prevent you from exercising or doing specific exercises? If yes, please explain.
Do you have any current or recurring injuries that make specific workouts or exercises painful or uncomfortable? If yes, do you have doctor’s restrictions or exercise limitations that I need to be aware of? *
If you are within 6 weeks post-pregnancy, has your doctor cleared you for exercise?
Have you ever had an exercise related medical condition?
PAR-Q
Has your doctor ever said that you have a heart condition OR high blood pressure?*
Yes
No
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?
Yes
No
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
Yes
No
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
Yes
No
Are you currently taking prescribed medications for a chronic medical condition? *
Yes
No
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. *
Yes
No
Has your doctor ever said that you should only do medically supervised physical activity? *
Yes
No
Payment
Clients must be members at Prairie Dunes Country Club to participate in small group personal training. Sessions are 1 hour in length and cost $20/session. Sessions are charged directly to your PDCC Member Account to be paid on a monthly basis. Please initial in agreement.
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