PERSONAL TRAINING CLIENT PACKET

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					                                                 PERSONAL TRAINING
                                                   CLIENT PACKET
                                                                                 2005-2006

Dear Participant:

Thank you for your interest in the Portland State University Campus Recreation Personal
Training Program. You are about to begin a one on one customized exercise regimen that
will be designed to meet your needs, goals, desires, and interests.

This packet includes information on trainer/client conduct, your health history, and your
exercise history and goals. It should be completed entirely and emailed to your personal
trainer at least 24 hours before your first session. The information in this packet will help
your personal trainer to develop a program specifically tailored for you; therefore, it is
important to answer all questions honestly. All information will be kept in confidentiality.
The following pages must also be printed and signed, and handed to the personal trainer
before your program begins on your first day:

       •   PSU Campus Rec: Participation Agreement, Assumption of Risk and Release
           (3 pages)
       •   Health History (3 pages)
       •   Medical Release Form (1 page, if necessary)
               o The Medical Release Form is strongly recommended if you fit into one
                  of the following groups:
                          Male and 45+ years
                          Female and 55+ years
                          You answered yes to one of the questions on the Health
                          History form, regardless of age
       •   Acknowledgement of Risks Without Medical Release Form (1 page, if
           necessary)

It is strongly recommended that all participants meeting at least one of the above criteria
listed under Medical Release Form be cleared by a physician prior to participation in a
personal training program. By meeting at least one of these criteria, you may be at an
increased risk for illness or injury.

If you have any questions or concerns, please contact Taylor Anderson at (503) 725-
2999.

                               Thank you,
                                     Taylor Anderson
                                     Fitness & Education Coordinator
                                     Portland State University Campus Recreation




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                                                   PERSONAL TRAINING
                                                     CLIENT PACKET


        Personal Trainer and Client Code of Conduct
The personal trainer will adhere to the following:

   1. Personal Trainers shall be committed to providing information that is consistent
      with both the requirements and the limitations of their profession.

   2. Personal Trainers shall preserve the confidentiality of privileged information and
      shall not release such information to a third party unless the client consents to
      such release or release is permitted or required by law.

   3. Personal Trainers and Clients shall comply with applicable local, state, and
      federal laws and with the PSU Campus Rec and Peter Stott Center (PSC)
      guidelines.

   4. Personal Trainers shall not misrepresent in any manner, either directly or
      indirectly, their skills, training, professional credentials, identity or services.

   5. Personal Trainers shall provide only those services for which they are qualified
      via education and/or experience and by pertinent legal regulatory process.

   6. Personal Trainers shall not engage in any form of conduct that constitutes a
      conflict of interest or that adversely reflects on the profession or on PSU Campus
      Recreation.

   7. Personal Trainers shall not place financial gain above the welfare of the Client
      being trained and shall not participate in any arrangement that exploits the clients.

   8. Personal Trainers shall never discriminate against any client based in race, creed,
      national origin, gender, religion, age, handicap/disability or other such legal
      classifications.

   9. If a personal trainer is late to a scheduled session, the missed time is owed at no
      charge to the client. If a trainer consistently arrives late, please contact Taylor
      Anderson at (503) 725-2999.

   10. Personal Trainer shall contact his/her client within 24 hours to cancel an
       appointment. Failure to notify client within this time period will result in the
       trainer training the client for free. If a trainer consistently cancels, please contact
       Taylor Anderson at (503) 725-2999.


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                                                   PERSONAL TRAINING
                                                     CLIENT PACKET

The client will adhere to the following:

   1. For personal training services, there is a $20/hour fee for students and a $30/hour
      fee for faculty/staff/alumni. This fee must be prepaid at the box office in Smith
      Center Student Union, and the client must present a valid ticket to the personal
      trainer at the beginning of each session.

   2. The client shall contact the personal trainer prior to their session to schedule a
      time. Any cancellations must be made at least 24 hours before the scheduled time,
      unless an emergency occurs.

   3. If the client is late to a session, the session will last until the end of the hour that
      was originally agreed upon. For example, if a session was scheduled for 2-3, and
      the client arrives at 2:10, the session will still end at 3. If a client is more than 15
      minutes late to a session, the trainer is not obligated to stay past that time to wait
      for the client.




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                                              PERSONAL TRAINING
                                                CLIENT PACKET

                               Health History
Participant Name:_________________________________________________________
Address:________________________________________________________________
Local Phone:_____________________________________________________________
Email:__________________________________________________________________
Birthdate:_______________ Age:__________ Gender:_________

Primary Health Care Provider:
Doctor:___________________________________ Phone:________________________
Address:________________________________________________________________

1. Do you smoke? Yes or No
If Yes, How often?________________________________________________________

2. How often, if at all, do you use alcohol? _____________________________________

3. Do you have high or low blood pressure? Yes or No
     If yes, what were the last 3 readings? ___/___; ___/___; ___/___

4. Do have any cardiovascular problems or disease? Yes or No
If Yes, Explain: __________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

5. Have you ever experienced chest pain when doing physical activity? Yes or No
If Yes, Explain: __________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

6. Do you ever loose consciousness or loose balance because of dizziness? Yes or No
If Yes, Explain: __________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

7. Are you pregnant or post-partum? Yes or No
If Yes, How many months are you?___________________________________________




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                                                PERSONAL TRAINING
                                                  CLIENT PACKET
8. Do you have diabetes? Yes or No
If Yes, Explain: __________________________________________________________
________________________________________________________________________
________________________________________________________________________

9. Have you had any surgery within the last 2 years? Yes or No
If Yes, Please explain: _____________________________________________________
________________________________________________________________________
________________________________________________________________________

10. Are you taking any medications (prescribed or not)?
Please list and explain: ____________________________________________________
________________________________________________________________________

11. Are you taking any supplements or vitamins?
Please list and explain: _____________________________________________________
________________________________________________________________________

12. When were you last seen by a physician?____________________________________

13. Do you have any injuries or orthopedic problems (bursitis, bad back, bad knees, etc.)?
       Yes or No
If Yes, Explain: __________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

14. Have you been told you have high cholesterol levels? Yes or No
If Yes, Explain: __________________________________________________________
________________________________________________________________________

15. Please check all conditions you currently have or have had in the past:
           Heart attack                                     Shortness of breath
           Diabetes                                         Anemia
           Stroke                                           Asthma
           Chest discomfort                                 Epilepsy
           Heart murmur                                     Anxiety or depression
           Trouble sleeping                                 Fatigue
           Migraine or headache                             Hernia
           Neck problems                                    Stomach problems
           Back problems                                    Limited range of motion
           Broken Bones                                     Arthritis


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                                               PERSONAL TRAINING
                                                 CLIENT PACKET
           Swelling of joints

Please, explain any conditions that you checked (i.e. treatment, symptoms, restrictions):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

16. Have you in the past or currently had/have any other medical conditions or problems
not previously mentioned in this form? Explain.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________


Consent Form

        I acknowledge that I am in good health, have answered the previous questions
truthfully, and have no known medical problems that would restrict my ability to
participate in this exercise program.

Participants Name (printed):______________________________________


Participants Signature: ____________________________________ Date:____________




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                                                      PERSONAL TRAINING
                                                        CLIENT PACKET

                              Medical Release Form
•   For all males 45 + years of age & females 55 + years of age, it is strongly recommended that you
    have a medical release completed by your physician before a trainer begins any fitness regimen
    with you.
•   If you answered yes to any of the questions on the Health History form regardless of age, it is
    also strongly recommended that you have a medical release completed by your physician before
    a trainer begins any fitness regimen with you.

Dear Doctor:
        Your Patient, ______________________________, wishes to start a personalized
fitness program with a personal trainer from Campus Recreation at Portland State
University.

The activity will involve but is not limited to: regular cardiorespiratory activity and
regular resistance training which will elevate his/her heart rate and blood pressure.

If your patient is taking medication that will affect his/her heart rate response to exercise,
please indicate the manner of the effect (raises, lowers, or has no effect on heart-rate
response):
Type of medication _______________________________________________________
Effect __________________________________________________________________

Please identify any other recommendations or restrictions for your patient in this exercise
program:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

                                 Thank you,
                                       Taylor Anderson
                                       Fitness & Education Coordinator
                                       Portland State University Campus Recreation
                                       Office: (503) 725-2999 Fax: (503) 725-5680

______________________________________ has my approval to begin an exercise
program with the recommendations or restrictions stated above.

Printed name ____________________________________ Phone__________________

Signed _______________________________________________ Date _____________


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                                                 PERSONAL TRAINING
                                                   CLIENT PACKET

                     Acknowledgement of Risks
                    Without Medical Release Form
It is strongly recommended that all participants meeting at least one of the following
criteria receive a physician’s clearance before engaging in any exercise program,
including those created by personal trainers through Portland State University Campus
Recreation:
         • You are male and 45+ years
         • You are female and 55+ years
         • You answered yes to one of the questions on the Health History form,
             regardless of age
By meeting at least one of these criteria, you may be at an increased risk for illness or
injury through participation in an exercise regimen. These associated risks include but are
not limited to: placing increased stress on the heart and increasing the risk of muscular-
skeletal injuries.

With regard to the above mentioned risks and others, and to those meeting the above
criteria, it is strongly recommended to be cleared by a physician before participating in
PSU Campus Rec personal training programs.

By signing below, you acknowledge the risks associated with exercise regimens, and
acknowledge the increased risk associated with them by meeting the aforementioned
criteria and refusal of obtaining a physician’s clearance before participation.


Printed Name: __________________________________________

Signature:______________________________________________ Date: ___________



Printed Witness Name:__________________________________________

Witness Signature: _______________________________________ Date: ____________




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                                                 PERSONAL TRAINING
                                                   CLIENT PACKET
                         Exercise History & Goals
1. Check which apply:
      □ I currently exercise         □ I do not regularly exercise, but would like to start.
      □ I used to be active, but am not anymore. I would like to become active again.

If you do currently exercise, list those activities in which you participate in and how
much time you spend doing each per week._____________________________________
________________________________________________________________________
________________________________________________________________________

If you do not currently exercise, why did you stop or why have you not exercised in the
past? ___________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. List any exercise, sport, or recreational activities that you have participated in within
the past 5 years. __________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. Circle the number that corresponds to the response which best describes you for each
of the following statements (1= low ability/interest, 5 = high ability/interest).
    Importance of completion during exercise.
        1      2         3     4      5
    How hard do you like to be pushed or motivated during exercise?
        1      2         3     4      5
    Present cardiorespiratory (aerobic) fitness.
        1      2         3     4      5
    Present muscular fitness.
        1      2         3     4      5
    Present flexibility.
        1      2         3     4      5

4. Do you start exercise programs but then find yourself unable to stick with them?
       Yes or No
If Yes, why? _____________________________________________________________
________________________________________________________________________
________________________________________________________________________

5. Specifically describe what you would like to accomplish through your fitness
program during the next:


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                                                PERSONAL TRAINING
                                                  CLIENT PACKET
   1 month ____________________________________________________________
   6 months _____________________________________________________________
   1 year    ____________________________________________________________

6. How much time are you willing to devote to an exercise program?
     Minutes per day _______      Days per week _______

7. What types of exercise equipment have you used or would like to use?
                                             Have Used     Would Like to Use
               Dumbbells                         □                   □
               Free Weights (plates)             □                   □
               Weight Machines                   □                   □
               Cardiovascular Machines           □                   □
               Body Weight Exercises             □                   □
Other (describe) ___________________________________________________

8. Which of the following exercise benefits are most important to you? Rate the
following goals in order of importance with 1 being most important and 11 being least
important.

___ Improve cardiovascular fitness                          ___ Increase strength
___ Body fat-weight loss                                    ___ Increase energy
___ Reshape or tone my body                                 ___ Feel better
___ Improve performance for a specific sport                ___ Enjoyment
___ Improve mood, decrease stress                           ___ Improve flexibility
___ Other _____________________

9. How many meals and/or snacks do you have per day? _____________________

10. Do you feel you eat healthy most of the time? Yes or No
If no, why not? ___________________________________________________________
________________________________________________________________________

11. How many glasses of water do you drink per day?
    □ 0-2           □ 3-5          □ 6-8          □ 9-12            □ more then 12

12. Please list any other considerations or information your trainer should be aware of
before getting started? (i.e. supplements, injuries, exercise or activities you can't/won't
perform, effective motivation techniques for you, etc.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________


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