Selders Personal Training Client Assessment Form

Full Name

First NameLast Name

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Email

example@example.com

E-mail

MEDICAL HISTORY

Do you have any of the following:

Rows	Yes	No
Chest Pain?
Coronary Heart Disease?
Rheumatic Fever?
High Cholesterol?
Irregular Heartbeats?
High Blood Pressure?
Family History of Heart Disease?
Chronic Cough?
Obesity?
Dizziness/loss of consciousness?
Arthritis?
Seizures or Convulsions?
Bone, joint, or muscle injury?
Severe Headaches?
Low Back Pain?

Have you had any family history of chronic disease (heart disease, diabetes, etc.)?

If yes, please list

Have you ever been diagnosed or treated for any chronic disease including asthma?

If yes, please list

Are you currently taking any medication?

If yes, please list

Any other conditions that we need to be aware of (i.e. Past or present injuries, etc)?

If yes, please list

PERSONAL DETAILS

If you have answered YES to any of the above questions, you must obtain a

medical clearance prior to carrying out a physical exercise program.

HEALTH RELATED BEHAVIOURS

Do you smoke?

If yes, how many a day?

Do you drink alcohol regularly?

If yes, how much per week?

How many times on average do you eat fast food per week?

How many hours of sleep do you normally get per night?

PSYCHOLOGICAL

Please rate the following. One star being negative to five stars being positive

I have a positive attitude towards things

My job stresses me out.

I am in the best shape of my life.

I would rate my current health.

GOALS

Do you have any health related goals (i.e. Lower blood pressure, etc)?

If yes, please list

Do you have specific goals related to body composition (i.e. weight loss, build biceps etc)?

If yes, please list

Do you have any performance specific goals (i.e. Increase 10km run, increase chest strength, etc.)?

If yes, please list

Do you wish to achieve any of these goals in a specific time frame?

If yes, please explain

LIABILITY WAIVER & INFORMED CONSENT
Please read carefully before submitting form.

I (the client)agree that if I engage in any physical exercise, class, or activity, I do so at my own risk. I agree that I am voluntarily participating in activities and assume all risk of injury or illness. I agree to release and discharge (my trainer) Tom Selders from any and all claims or causes of action (known or unknown) arising out of my negligence. I acknowledge that I have carefully read this waiver and Release and fully understand that it is a release of liability. I am waiving any right that I may have to bring a legal action to assert a claim against my trainer for his/her negligence.

Please tick box in agreement to the above informed consent and liability waiver.

Signature

Tom Selders PERSONAL TRAINING CLIENT ASSESSMENT