New Client Information Sheet
Prairie Dunes Country Club
First and Last Name:
*
Home Address:
*
Best phone number to contact you:
*
Best email address to contact you:
*
Occupation
*
Does your occupation require manual labor? If yes, please explain.
How did you hear about AbbeySnell Fitness?
*
What type of program are you signing up for?
*
Personal Training
Group Fitness
Prairie Dunes Member Number (for billing purposes only):
Age:
*
Are you currently pregnant or breast feeding? If yes, when is your due date?
Current Exercise Schedule
How many days of the week do you currently exercise?
*
Are you currently on an exercise program? If so, please explain.
What are your personal goals for starting this program? Be specific! (ex: muscle growth, weight loss, variation of routine)
*
Cardio
How often do you currently do cardio?
*
How long is your normal cardio workout?
*
What is an example of a cardio workout you would typically do?
*
Strength Training
How often do you strength train?
*
How long is your typical strength training workout?
*
Physical/Medical Information
Describe your current level of physical fitness. *MUST be at least Intermediate level to participate in BOOTCAMP. Any level welcome for Personal Training.
Beginner
Intermediate
Advanced
Has it been over 1 year since you have exercised? If yes, for a particular reason?
*
Have you been hospitalized in the past 5 years? If yes, for what reason? When?
*
Do you have high blood pressure? If yes, what is it?
*
Do you have high Cholesterol? If yes, what is it?
*
Do you have diabetes? If yes, please explain.
*
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?
*
Have you previously smoked? If yes, please explain when, for how long, and when you quit.
*
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?
*
Please list ALL physical limitations, aches, pains, ailments, past or current injuries you have that could interfere with exercise. Please be specific!
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
Submit
Should be Empty: