Client information & medical record

First Name

Last Name

Age

DOB

Phone number

How will you attend?

Physically

Online

Is this your first time attending?

Yes

Height?

Weight? (kg)

Has your doctor ever said you should consult them before undertaking activity?

Yes

Details?

Do you feel pain in your chest during physical activity?

Yes

Details?

Do you have high blood pressure?

Yes

Do you lose balance, feel light headed or have dizzy spells?

Yes

Details?

Have you been in hospital in the last 12 months?

Yes

Details?

Has your doctor ever said you have heart trouble?

Yes

Are you currently taking medicine?

Yes

Details?

Do you suffer from arthritis that is aggravated by exercise?

Yes

Details?

Are you pre or post natal?

Yes

Months?

Do you suffer from asthma or breathing difficulties?

Yes

Details?

Do you suffer from diabetes?

Yes

Do you suffer from epilepsy?

Yes

Are you healthy enough to train at Body Evolution Fitness

Yes

If you answered YES to any of the above questions, please provide a doctors note before training. Check box to aknowledge.

Please note; If your health changes in any way during your new fitness regime or physical activity, please consult your fitness professional and seek advice from your doctor immediately. Check box to aknowledge.

Are you experiencing any stress at the moment? Any mood swings, relationship or work issues for which you would like to recieve some help or resources?

Yes

has anyone in your family developed heart disease prior to 60 years old?

Yes

Are you taking or recently used any prescription or over the counter medications?

Yes

Please give the details and dosages below.

Have you had any surgical operations in the past 10 years?

Yes

Details?

Are you currently under doctors care? If so, please give details below.

Yes

Please give more details.

Have you any concerns that you would like to discuss with me or a doctor?

Yes

Please give more details.

Do you currently smoke?

Yes

How many and how long have you smoked?

Do you drink alcohol?

Yes

How many units per week?

Personal Goals

In number order, tell me what are your 3 main goals and the timescale that you would like to achieve them in?

Add most important goal here:

Timescale?

Add second most important goal here:

Timescale?

Add third most important goal here:

Timescale?

Past Exercise History

Are you currently exercising / training? If no skip this section

Yes

How long have you been training / exercising?

1-3 months

3-6 months

6-12 months

longer

How many times per week do you train?

1-3 days

3-5 days

6-7 days

Which types of exercising / training do you do?

Resistance (lifting weights)

Cardio (running, cycling, swimming etc

Sport

Rehab

In the box below, please let me know your weekly schedule for exercising or training.

Lifestyle

What is your job?

Do you work night shifts?

Yes

Do you work from home?

Yes

What are your daily stress levels?

Low (rarely stressed at home or work)

Moderate (occasionally have to deal with stressfull situations, but handle them well)

High (often dealing with stressfull situations that do have an effect on me)

Very high (constantly stressed at home and work, probably effect my life and health)

What are your biggest stresses?

Do you get bloated or gassy?

Yes

Do you know which foods make you bloat or gassy??

Can you tell me your daily routine. What time you get up, what time you eat your meals, what time do you go to work, pick up kids, go to the gym etc

Miscellaneous

Is there any informationyou would like to include that you feel may be important?

Social support

Do the people who spend time with each day follow a healthy lifestyle by exercising or eating healthy foods?

Yes, most of them do (+3)

At least half of them do (0)

No, most of them don't (-3)

Does your partner or spouse follow healthy lifestyle habits such as exercising regulary and eating healthy foods?

Yes, they do (+5)

No, they don't (-5)

I don't have a partner or spouse (0)

When you want to go for a walk, bike ride, exercise etc is it easy to find a companion to go with you?

Yes, it's easy to find someone (+2)

Yes but infrequently (0)

i can't find anyone (-4)

At work do your co workers often bring in cakes, sweets, takeaways and other treats?

Yes, often (-4)

yes, but I don't indulge (0)

No they don't (+5)

if you eat out, do the people you eat out with order healthy choices?

Yes, they always do (+2)

Only half the time (0)

No they never do (-2)

Do spend more than 50% of your week with someone who regulary drinks alcohol on a regular basis?

Yes, (-5)

No (0)

Do you feel like you drink alcohol because of other people (peer pressure)

Yes, 100% (-5)

Somethimes 50% (-2)

No it's 100% my own influence (0)

We don't drink alcohol (+5)

Do you belong to any groups or social groups that meet up and do some form of physical activity? (not including gym memberships)

yes, been a member for years (+5)

yes, just started (+2)

no I don't (0)

Are you a member at a gym or health club?

Yes, for at least 1 year (+2)

Yes, just joined (+1)

No I don't (0)

When discussing your health plan with your friends do they seem interested and keen or are they unsupportive?

Yes, they are very interested (+2)

No they are not interested (0)

No they are telling not to do it (-2) (0)

Do the people you live with bring home unhealthy foods?

Always, (-5)

Sometimes (-3)

Never (0)

Do the people you live with schedule activities that interfere with your health plan?

Always, they don't respect my time (-3)

Sometimes, they don't think about it (-1)

Never, they respect my time (+3)

Do the people you live with provide you with information on health, nutrition and exercise that could aid you in your health goals?

Always, (+5)

Sometimes, (+2)

Never (0)

Thanks for submitting!

Your score

28 to 38

5 to 19

4 to -14

-14 to -31

Terms & Conditions
Small Group Personal Training
& Personal Training

Background

These Terms and Conditions are the standard terms which apply to the provision of Small Group Personal Training (SGPT) & Personal Training Services by Body Evolution Fitness.

This agreement is based on the following provisions:
1. We will deliver you the best possible training and lifestyle programmes in line with your chosen goals.

2. Your results are dependent on you following the programmes/instruction and completing your allocated sessions.

3. You are responsible for your own state of health, physical condition and wellbeing.

4. 24 hours notice is required for all cancellations otherwise you will be charged for the session.

5. Payment must be made in advance of any sessions or assessments being delivered.

1. The agreement is a strict time period as indicated in the weekly schedule provided, not a count of sessions.

6. Unused SGPT sessions will only be carried forward at your coaches discretion.

7. Cancellation or early termination of this agreement will only be considered on the occurrence of one of the following, our decision on this is final:
i) Serious Illness. ii) Accident/Injury. iii) Bereavement. iv) Redundancy v) Relocation to more than 25 miles from our premises.

8. A months notice is required for cancelation of subscription other than the circumstances listed above.

9. Late payments will be charged an extra £10 on top of the requested amount due. Which will continue for every calendar week until full payment received.

10. Body Evolution reserves the right to cancel subscriptions due to constant late payments.

By ticking 'Yes' below I agree and sign to these terms and conditions

Sign this agreement?

Yes