Download the Fitness Trainers Inc. Informed Consent form

Please answer the following questions so that we may:

1. Help determine your goals

2. Develop a plan to achieve your goal based on your individual lifestyle, preferences and medical history.

3. Gather critical information to expedite your training.

4. Have you consulted with an FTI Employee? If so, who did you speak with?

Please Choose Your Location:

King Street Pure Energy Private Residence Aronimink Applebrook White Manor Valley Forge Physical Therapy Berwyn Squash and Fitness Premier Orthopaedics Physical Therapy

Personal Information

First Name:
Last Name:
Gender:	Male Female
Address:

City:   State:   ZIP:

Email Address:
Contact Number:
Emergency Contact Name:
Relationship:
Emergency Contact Number:

Occupation/Title:

Company:

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Health Insurance Company:
Policy Number:

Address:

City:   State:   ZIP:

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I. Goals

What would you like to accomplish through an excercise and/or nutrition program?

Look Better

Decrease Body Fat  

Increase Muscle Tone/Definition  

Increase Muscle Mass  

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Feel Better

Increase Energy Level  

Decrease Stress  

Decrease Pain  

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Perform Better

Increase Cardiorespiratory Endurance  

Increase Strength  

Increase Muscular Endurance  

Increase Flexibility  

Sports Specific Results  

Improve Medical Condition  

Improve Quality of Life  

Please share more information with us about your goals:

II. Utilization of Services

What component of our services would best help you accomplish your goals?

EDUCATION (What to do and how to do it)

MOTIVATION (Help getting it done)

ACCOUNTABILITY (Make sure it gets done)

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Realistically, how many total days per week can you commit to exercising?

1      2      3      4      5      6      7

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Realistically, per session, how much time can you dedicate to personal training?

less than 30 min.      30 min.      45 min.      60 min.      60+

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What are the most convenient days and times for you to exercise?

Monday      A.M.    P.M.

Tuesday      A.M.    P.M.

Wednesday      A.M.    P.M.

Thursday      A.M.    P.M.

Friday      A.M.    P.M.

Saturday      A.M.    P.M.

Sunday      A.M.    P.M.

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III. Lifestyle

What activities/excercise programs are you involved in? What activities/excercises do you like/dislike?

1	1_Activity	1_Frequency	1_Duration
2	2_Activity	2_Frequency	2_Duration
3	3_Activity	3_Frequency	3_Duration

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How would you rate your current nutrition habits?

Excellent      Good      Fair Need Improvement

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How has your weight fluctuated more than 10lbs. in the past 5 years?

Yes      No       

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If any, what nutritional habits need the most improvement?

Food Selection (what you eat)

Behavior (where, when and how you eat)

Quantity Control (how much you eat)

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Are you presently taking a:

Multivitamin      Antioxidant      Other supplement  

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How would you grade your current stress level?

No Stress      Fair      High      Overwhelmingly High

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What contributes the most to your stress level?

Family

Work

Medical Condition

Finances

School

IV. Health & Medical History

*Age:    *Date of Birth:

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Do any of these apply to you?

High Blood Pressure Yes No

Blood Pressure Reading:

High Cholestoral >200 Yes No

Cholestoral Reading:

Smoking (currently) Yes No

How many?

Smoking (past) Yes No

How long?

Diabetic? Yes No

Abnormal EKG? Yes No

Family History of Heart Disease?

Who    Age

Who    Age

Who    Age

Who    Age

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Do have any limitations or special considerations in the following areas?

Neck  

Shoulder  

Elbow/wrist/forearm  

Spine  

Lower Back  

Hip/pelvis  

Knee  

Ankle/foot/toes  

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Chronic conditions/illnesses?

Type and History:

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Current Medications

Type and History:

If you are currently taking more than 3 medications bring a medication list to your consultation.

Physician Name:
Phone:
Address:

City:   State:   ZIP:

Date of last physical:

FTI has permission to contact my Physicians and correspond in regards to my fitness/exercise program

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How did you find out about our services?

Physician referral

Family, friend, business associate

Club Staff

Brochure

Website

Yellow Pages

Promotional Event

Marketing boards

Observation of appointment

Email

Bryn Mawr Rehab

Other: