EMS TRAINING AND WELLNESS HOME OF MUSCLE-MOM ACADEMY
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Client Details
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Indicates required field
Full Name
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Age
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Date of Birth (DD/MM/YY)
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Email
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Client Readiness for Activity
HAS YOUR DOCTOR EVER SAID THAT YOU HAVE A HEART CONDITION AND THAT YOU SHOULD ONLY PERFORM PHYSICAL ACTIVITY RECOMMENDED BY A DOCTOR?
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Yes
No
DO YOU FEEL PAIN IN YOUR CHEST WHEN YOU PERFORM PHYSICAL ACTIVITY?
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Yes
No
IN THE PAST MONTH, HAVE YOU HAD CHEST PAIN WHEN YOU WERE NOT PERFORMING ANY PHYSICAL ACTIVITY?
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Yes
No
DO YOU LOSE YOUR BALANCE BECAUSE OF DIZZINESS OR DO YOU EVER LOSE CONSCIOUSNESS?
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Yes
No
DO YOU HAVE A BONE OR JOINT PROBLEM THAT COULD BE MADE WORSE BY A CHANGE IN YOUR PHYSICAL ACTIVITY?
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Yes
No
IS YOUR DOCTOR CURRENTLY PRESCRIBING ANY MEDICATION FOR YOUR BLOOD PRESSURE OR FOR A HEART CONDITION?
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Yes
No
DO YOU KNOW OF ANY OTHER REASON WHY YOU SHOULD NOT ENGAGE IN PHYSICAL ACTIVITY?
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Yes
No
IF YOU HAVE ANSWERED YES TO ONE OR MORE OF THE ABOVE QUESTIONS, CONSULT YOUR DOCTOR BEFORE ENGAGING IN PHYSICAL ACTIVITY. TELL YOUR DOCTOR WHICH QUESTIONS YOU ANSWERED YES TO. AFTER MEDICAL EVALUATION, SEEK ADVICE FROM YOUR DOCTOR ON WHAT TYPE OF ACTIVITY IS SUITABLE FOR YOUR CURRENT CONDITION.
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I understand
General & Medical History
Occupational
WHAT IS YOUR CURRENT OCCUPATION?
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DOES YOUR OCCUPATION REQUIRE EXTENDED PERIODS OF SITTING?
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Yes
No
DOES YOUR OCCUPATION REQUIRE REPETITIVE MOVEMENTS?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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DOES YOUR OCCUPATION REQUIRE YOU TO WEAR SHOES WITH A HEEL (E.G., DRESS SHOES)?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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DOES YOUR OCCUPATION CAUSE YOU MENTAL STRESS?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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Recreational
DO YOU PARTAKE IN ANY RECREATIONAL PHYSICAL ACTIVITIES? GOLF, RUNNING, GOING TO THE GYM, ETC.
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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How often, to what level, etc.
DO YOU HAVE ANY ADDITIONAL HOBBIES? READING, VIDEO GAMES, ETC.
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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Medical
HAVE YOU EVER HAD ANY INJURIES OR CHRONIC PAIN?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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HAVE YOU EVER HAD ANY SURGERIES?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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HAS A MEDICAL DOCTOR EVER DIAGNOSED YOU WITH A CHRONIC DISEASE, SUCH AS HEART DISEASE, HYPERTENSION, HIGH CHOLESTEROL, OR DIABETES?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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ARE YOU CURRENTLY TAKING ANY MEDICATION?
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Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
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Additional Information
IS THERE ANY ELSE YOU THINK I MAY NEED TO KNOW THAT MAY EFFECT YOUR ABILITY TO TRAIN. (THIS IS OF COURSE IN TOTAL CONFIDENCE).
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Client Agreement
APPOINTMENT TIMES WILL BE MUTUALLY AGREED WITH YOUR TRAINER. YOUR CONTACT DETAILS ARE SECURELY HELD BY YOUR PERSONAL TRAINER AND WILL REMAIN CONFIDENTIAL. TRAINING SESSIONS ARE 60 MINS IN LENGTH. YOU WILL ARRIVE ON TIME FOR YOUR SESSION IN APPROPRIATE CLOTHING AND READY TO TRAIN AS SESSIONS CAN’T BE DELAYED BEYOND THEIR SCHEDULED TIME.
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I understand
IF YOU DO NOT GIVE 24 HOURS NOTICE OF CANCELLATION, YOU'll BE CHARGED FOR THAT SESSION. IF YOU DO NOT ATTEND YOUR BOOKED SESSION YOU WILL BE CHARGED FOR THAT SESSION. IF YOU ARE LATE FOR A SESSION IT WILL STILL END AT THE SCHEDULED TIME. ALL SESSIONS MUST BE PAID FOR IN ADVANCE.
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I understand
I HAVE AGREED TO UNDERTAKE IN A PROGRAM OF PHYSICAL EXERCISE UNDER THE INSTRUCTION OF [Trainer Name] FROM [Business Name]. TRAINING MAY INCLUDE, BUT IS NOT LIMITED TO, WEIGHT AND/OR RESISTANCE TRAINING, CARDIOVASCULAR TRAINING, AND FLOOR MAT EXERCISES. [Trainer] FROM [Business Name] AGREES TO INSTRUCT, ASSIST AND TRAIN ME. I REALISE THAT A LARGE PORTION OF MY SUCCESS WILL BE BASED ON MY COMMITMENT TO FOLLOW INSTRUCTION, CHANGING MY LIFESTYLE, AND MY ATTITUDE TOWARDS THE FITNESS PROGRAM. UNFORTUNATELY, [Business Name] CANNOT GUARANTEE RESULTS, BUT MY WILLINGNESS TO WORK HARD WILL IMPROVE THE OPPORTUNITY OF SUCCESS. I HAVE READ THE ABOVE POLICY AND AGREE TO ITS TERMS AS IT APPLIES TO MY PERSONAL TRAINING PACKAGE.
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I agree
BY CLICKING ‘I AGREE’ & SUBMITTING THIS COMPLETED FORM, YOU CONFIRM THAT YOU HAVE READ, UNDERSTOOD AND COMPLETED THE PAR QUESTIONNAIRE AND ANSWERED ALL QUESTIONS TRUTHFULLY, TO THE BEST OF YOUR KNOWLEDGE.
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I agree
Submit
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