Personal Training Participant Info

First Name

Last Name

Age

Phone

Contact Email

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relation

If participants is between ages 12-17, parent information is required.

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

This health history form is intended to obtain relevant information about your health that will assist the staff in helping you with your program. Please answer all questions to the best of your knowledge.

Height

Weight

Health History

Questions	Yes	No
Do you have high blood pressure?	Yes	No
Have you had high blood pressure in the past?	Yes	No
Are you on medication for high blood pressure?	Yes	No
Do you Smoke?	Yes	No
Are you a former smoker?	Yes	No
Do you have Diabetes?	Yes	No
Have you ever had a heart attack?	Yes	No
Have you had heart surgery?	Yes	No
Do you have angina?	Yes	No
Have any of your blood relatives had heart disease, heart surgery or angina?	Yes	No
Do you have any serious orthopedic programs that would prevent you from exercising?	Yes	No

If you are a former smoker, please give the date you quit smoking

Please list any orthopedic problems

Please list all medications you currently take

Do you have any reason to believe you should not exercise?

Yes

Were you a high school and/or college athlete?

Yes

If yes, please specify:

If yes, please explain

Please rate your exercise level on a scale of 1 to 5 (5 is very strenuous) for each age range through your present age:

Questions	1	2	3	4	5
15-20 years of age	1	2	3	4	5
21-30 years of age	1	2	3	4	5
31-40 years of age	1	2	3	4	5
40-50+ years of age	1	2	3	4	5

Do you have any negative feelings toward or have you had any bad experience with fitness testing and evaluation?

Yes

Do you start exercise programs but then find yourself unable to stick with them?

Yes

If yes, please explain:

How many minutes/day are you willing to devote to exercise?

How many days a week are you willing to devote to an exercise program?

Rate yourself on a scale of 1 to 5 (1 indicating the lowest value and 5 the highest).

Questions	1	2	3	4	5
Characterize your present athletic ability	1	2	3	4	5
When you exercise, how important is competition?	1	2	3	4	5
Characterize your present cardiovascular capacity	1	2	3	4	5
Characterize your present muscular capacity	1	2	3	4	5
Characterize your present flexibility capacity	1	2	3	4	5

Are you currently involved in regular cardiovascular exercise?

Yes

If yes, specify the type of exercise(s)

How many days a week do you currently exercise?

How many minutes a day do you currently exercise?

Exertion Level

Questions	Light	Fairly LIght	Somewhat Hard	Hard
Rate your perception of the exertion of your exercise program	Light	Fairly LIght	Somewhat Hard	Hard

How long have you been exercising?

What other exercise, sport, or recreational activities have you participated in the past 6 months?

What other exercise, sport, or recreational activities have you participated in the past 5 years?

Exercise & Your Job

Questions	Yes	No
Can you exercise during your workday?	Yes	No
Would an exercise program interfere with your job?	Yes	No
Would an exercise program benefit your job?	Yes	No

What Types of exercise interest you?

Questions	Yes	No
Walking	Yes	No
Jogging	Yes	No
Swimming	Yes	No
Cycling	Yes	No
Dance Exercise	Yes	No
Strength Training	Yes	No
Stationary Biking	Yes	No
Rowing	Yes	No
Tennis	Yes	No
Other Aerobic Exercise	Yes	No
Stretching	Yes	No

Rank your goals in undertaking exercise: What do you want exercise to do for you? (1 = Extremely Important, 5 = Somewhat Important, 10 Not at all Important)

Questions	1	2	3	4	5	6	7	8	9	10
Improve Cardiovascular Fitness	1	2	3	4	5	6	7	8	9	10
Body-fat weight loss	1	2	3	4	5	6	7	8	9	10
Reshape or tone my body	1	2	3	4	5	6	7	8	9	10
Improve performance for a specific sport	1	2	3	4	5	6	7	8	9	10
Improve moods and ability to cope with stress	1	2	3	4	5	6	7	8	9	10
Improve flexibility	1	2	3	4	5	6	7	8	9	10
Increase strength	1	2	3	4	5	6	7	8	9	10
Increase energy level	1	2	3	4	5	6	7	8	9	10
Feel better	1	2	3	4	5	6	7	8	9	10
Enjoyment	1	2	3	4	5	6	7	8	9	10
Other	1	2	3	4	5	6	7	8	9	10

By how much would you like to change your current weight?

Please write down your goals of the personal training session. Be as specific as possible.

I hereby certify that I or my teen is in normal health and capable of safe participation in the program in which I or he/she am enrolling.

I understand that the program will involve a certain degree of strenuous physical activity. I agree to assume all risks associated with the program and further agree to hold the YMCA harmless from and against any and all liability, loss, claims, costs and expenses, for both personal injury and/or property damage, including attorney fees, which may arise as a result of my participation in the YMCA Strength Training Programs.

In the event of an emergency, and emergency contact cannot be reached, I hereby authorize the YMCA to obtain medical treatment for myself or my teen at my expense.

Participant Signature (or Parent/Guardian Signature if participant 12-17 years)

Sign above

Date

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