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Please fill the Medical Questionnaire and Informed Consent form

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Client No. Copied Yes No

Medical Questionnaire and Informed Consent

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CUSTOMER DETAILS

Applicant 1
Title: Mr/Mrs/Ms/other Contact Name
First Name: Surname:
Date of Birth:    
Address
  Postcode
Telephone: Mobile:
Email: Type of membership required:
Emergency Contact Details:    

DECLARATION

I/we hereby agree to abide by the terms and conditions of Dan Bennett MBF Personal Training, a copy of which I/we have read and retained.
Signed: Date:

SECTION 1 Part A

Common sense is your best guide to answering these questions. Please read them carefully and tick the correct answer.
Yes No  
1. Has your doctor ever said you have heart trouble?
2. Do you, or have you ever had, unexplained pains in your chest?
3. Are you currently or have you ever received treatment for epilepsy?
4. Has your doctor ever told you that you have a bone or joint problem such as arthritis that may be made worse by exercise?
5. Have you ever been diagnosed as diabetic?
6. Has a doctor ever said your blood pressure was too high? (Except during pregnancy)
7. Are you pregnant?
8. Are you taking any medication prescribed by your doctor for your blood pressure, a heart condition or other serious illness?
9. Are you over 55 and not accustomed to exercise?
10. Is there a good reason not mentioned here, why you should not follow an activity programme even if you wanted to?

SECTION 2 Part B

The information below is designed to help the instructor in prescribing safe and suitable activity for you. Please answer carefully and to the best of your knowledge.
Yes No  
Have you ever had your blood cholesterol measured?
If yes, was it high?
Is there any family history of heart disease in parents or siblings less than 55 years old?
Do you smoke or have you been smoking within the last 6 months?
    If yes, how many cigarettes/cigars do you smoke each day?
Would you like to give up?
Do you, now or have you ever been treated for the following? (if yes please give details)
Yes No    
Chest complaints e.g. Asthma
Surgery
Fractures
Muscle/Ligaments sprains
Knee/Back pain
CURRENT ACTIVITY LEVELS
Yes No  
Do you frequently exercise at the moment? If yes, Yes No please give details
   
Yes No  
Do you participate in any other leisure activities that make you out of breath? If yes, please give details
   
    Is your occupation predominately active or sedentary?
   

SECTION 3 LIFESTYLE QUESTIONNAIRE Part C

EXERCISE GOALS:
1. What are your reasons for training with a Personal Trainer?
2. What activities would you like to participate in?
3. How frequently would you like to participate in these activities (please tick)
Less than 1 x week 1-2 x week 2-3 x each week 3+ x each week Sporadic usage
4. How long will you have to exercise for each session?
5. Do you have any concerns about exercising with a Personal Trainer?
6. On a scale of 1-5 how motivated are you to exercise?
1 Not motivated 2 3 4 5 Very motivated

SECTION 3 Part C Continued

YOUR FITNESS BACKGROUND:
1. What are your reasons for training with a Personal Trainer? Yes No
8. How long have you been exercising (please tick)?
6 months 6 months-1 year 1-2 years 2-5 years 5+ years
9. Briefly describe your previous routine
10. When exercising in your previously, were there any exercises you particularly liked or disliked?
Likes
Dislikes
NUTRITION:
Yes No  
11. Are you happy with your diet?
12. Would you like advice to improve your diet?
13. Do you drink alcohol? If yes, how many units per week? (1 unit = 1/2 pint of beer, 1 glass of wine, 1 spirit measure)
14. Do you drink tea, coffee, or cola? If yes, how many cups/glasses per day?
I have answered these questions to the best of my knowledge and will alert my trainer and D Bennett MBF Personal Training should any changes occur in the above information.
Signature: Personal Trainers signature:
Date: Date:
FOR OFFICE USE ONLY Induction Date:
Registration fee:
Receipt Number(s): Method of Payment:
Processed by: Date:
Client Category Used:
MBF Personal Training, 9 Orchard Close, Burgess Hill, East Sussex. RH15 0GF
Tel: +44 (0) 1444 230566