Q1 by ashrafp


									    Pele Reid

All information received on this form will be treated as strictly confidential. This
information is essential to helping me to develop a program that addresses your needs,
goals and interests and is safe and effective:

Name: _____________________________ Date of Birth____/____/____

Age:_______________ weight _________________          Height ____________________

Address: ________________________________________________________________


Telephone: Home________________________ Mobile__________________________

Email Address:___________________________________________________________


Emergency Contact:


Phone Number: ________________________________

GP’s Name:______________________         GP’s Phone____________________________

Hobbies and Interests:

Please mark YES or No to the following:

Has your doctor ever said that you have a heart condition and recommended only
medically supervised physical activity? ____
    Pele Reid

Do you frequently have pains in your chest when you perform physical activity?

Have you had chest pain when you were not doing physical activity? ____

Do you lose your balance due to dizziness or do you ever lose consciousness? ____

Do you have a bone, joint or any other health problem that causes you pain or limitations
that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis,
high blood pressure, high cholesterol, arthritis, Anorexia, bulimia, anaemia, epilepsy,
respiratory ailments, back problems, etc.)? ____

Are you pregnant now or have given birth within the last 6 months? ____

Have you had a recent surgery? ____ If YES to any of the above, please elaborate below:




Do you take any medications, either prescription or non-prescription, on a regular basis?
Yes/No What is the medication for?


How does this medication affect your ability to exercise or achieve your fitness goals?


Have you ever had, or do you currently suffe r from, any of the following ailments?
      Arthritis or rheumatism?
      Asthma, emphysema or bronchitis?
      Stiffness or pain in your Neck?
      Backache or Scoliosis?
      Pain in your knees?
    Pele Reid

      Sore feet?
      Heart disease?
      Any other chronic illnesses?
      High blood pressure?
      Raised cholesterol levels?
      Any other health problems?


Do you smoke? YES NO

If yes, how many daily? _________

Do you drink alcohol? YES NO If yes, how many glasses per week? __________

How many hours do you regularly sleep at night? ___________

Describe your job: Sedentary / Active / Physically Demanding


On a scale of 1-10, how would you rate your present fitness level (1=Worst; 10=Best)?


On a scale of 1-10, how would you rate your Nutrition (1=very poor; 10=excellent)?

How many times a day do you usually eat (including snacks)? _______________

Do you skip meals? YES NO

Do you eat breakfast? YES NO

Do you eat late at night? Sometimes Often Never

How many glasses of water do you consume daily? _____________
    Pele Reid

Are you currently or have you ever taken a multivitamin or any other food supplements?
Y N If yes, please list the supplements:


Do you require nutritional advice? _______

What are your pe rsonal fitness goals?

      Improve Cardiovascular (heart / lung) efficiency
      Gain muscle mass / definition
      Improve fitness level
      Tone-up all muscle groups
      Reduce stress levels
      Reduce body fat
      Improve Cardiovascular (heart / lung) efficiency
      Gain muscle mass / definition
      Improve fitness level
      Tone-up all muscle groups
      Reduce stress levels

Other :

Which body areas do you want to target?

How do you see fitness now?
    Pele Reid

Is there anything you feel will prevent you from achieving your goals?

What are your preferred training methods?

   □ Boxing (Pad work, techniques, combinations)
   □ Running (Road work, fartlek varied pace during the run)
   □ Self-defence techniques
   □ Traditional king fu
   □ Kick boxing
   □ Circuit Training / Body Condition / Strength Work
   □ Japanese K1 Style kick boxing
    Pele Reid

During all training sessions I AGREE TO:

    Wear loose comfortable clothing

    Wear Trainers / sensible footwear suitable for exercising

    Stay hydrated by having a bottle of water / energy drink close by

    Let Pele know periodically how I feel about the training session (too hard, too
     easy, just right!)

    Ask for a water break if I need it.

After the training session

    Take part in stretching and cool down exercises

    feedback any thoughts which can be taken into consideration for the following
    * Your questions and feed back enable me to train and motivate you to achieve
    your fitness goals - our shared

Before the training session

    Inform Pele of any aches, pains or illnesses have I that I have had since the
     previous session.

    Let Pele know if I need to cancel a session by calling him at least 24 hours before
     the scheduled time.



    Pele Reid

Pele Reid, your personal fitness trainer, strongly recommends that you consult your
doctor and get medical approval before beginning any fitness and / or exercise


   1. You have been informed of the need for medical approval before joining in the
      fitness exercise and training program which Pele Reid will design for you.

   2. You are voluntarily choosing to participate in a physical exercise program

   3. You agree that any information, instruction or advice obtained from Pele Reid
      must NOT be used as a substitute for your doctor's advice or treatment.

   4. You agree that any information, instruction or advice obtained from Pele Reid
      will be used at your own risk.

   5. You agree to release and discharge Pele Reid from any and all responsibilities or
      liabilities from injury arising from your participation in any exercise program
      designed by Pele Reid on your behalf



    Pele Reid

When you book me as your Personal Trainer you
will receive:

1). A complete workout plan and nutrition plan (if required) prepared personally
by me. Your training schedule will be based on:

      Your chosen fitness goals
      Your chosen training methods
      your personal fitness and health level.

2). Safe personal training plan based on safe and correct technique(s). *16
years of practical teaching experience, national and international sports
championship titles and my certification studies have taught me that this is the
only effective way to avoid injuries and achieve your full potential.

3). A weekly’ feedback and motivate’ by phone or email including updates to
your exercise schedule as you progress and nutrition tips.

4). 100% Respect, patience and support.

Name: Pele Reid_________________________


    Pele Reid

                 Train like a fighter…without the fight!

“My aim is to use the training principles and artistic elements
of boxing and martial arts to assist my clients in achieving
their highest level of health and fitness.”
                                                    Pele Reid

Session:                 Standard training session last 1 hour and 30 minutes
                         Includes 15 minutes - warm up,15 minutes cool
                         down & stretch
                         Earliest session 6.00am. Latest session: 9.00pm

Rates                    Sessions prices start at £50.00
                         Pay for a block of 5 sessions in & get 1 free
                         Recommend a friend and get 1 free session
                         Group session: Minimum of 4 maximum of 6 people -
                         £150.00 per group
                         Wedding packages available!

Initial consultation     FREE!
                         Questionnaire on health status, lifestyle, health and
                         fitness goals, preferred training methods, training

Training Venue           Your local gym
                         G & A Fitness in Garretts Green
                         Your local park (weather permitting)
                         Your own home (if space is adequate). *For women
                         there must be another adult present and in view of
                         the training session

For more information visit www.pelereid.co.uk

Contact: Pele Reid on 0790 3857 862   Email:
    Pele Reid


Appointment / Date:___________________________


Summary of fitness goals:


Training methods employed

Fedback from client


Pele Reid

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