Personal Trainer Consultation Form 2b533p

Personal Trainer Consultation Form Title: Mr, Mrs, Ms Miss

Full Name:

Gender: Male/Female

Date of birth:

Address:

Postcode:

E-mail: Home number: Mobile number: GP Details Name of Doctor:

Number:

Surgery address:

Emergency s Name:

Relation:

Number:

Occupation: Medical history (i.e. injuries or illnesses) Have you had any recent injuries or illnesses? Yes/no (if yes please tick the boxes) Heart attack Sunburn

Stroke High blood pressure Asthma Seizures Sunstroke

Diabetes

Cancer Fever Viral infection

Fractures Cuts and Bruises Rashes Dislocation Concussion Other

Below in the box please explain in more detail.

Are you pregnant? Yes/no (if yes please state how many weeks) Have you recently visited your GP? Have you had any operations recently? Is there anything else I need to know about? Lifestyle Do you smoke: yes/no Do you drink alcohol: yes/no Do you take drugs: yes/no How many hours do you sleep: Are you allergic to anything: Is there anything that you can’t do: What do you want to achieve in this training program: Do you stress and what causes you to stress: How many litres of water do you drink per day: Physical Examination Height: Weight: BMI: Body fat %: Blood pressure: Lung function: Postural Analysis

Declaration I understand that all information is kept confidential and private unless permission is given to disclose. Any changes in my personal circumstances must be given to personal trainer immediately. I hereby indemnify the personal trainer against any adverse reaction sustained as a result of treatment I understand the training plan that has been proposed to me/ I confirm all the information above is correct. Client signature: Date: Personal trainer signature: Date: