Physical Activity Readiness Questionnaire

Consent/Release Form

This program consists of various phases designated to determine your readiness to engage in physical activity, measure your functional fitness capacity in several areas, record objective data in relation to your current fitness levels & on an ongoing basis, regularly update & evaluate your current health & fitness status.

During the first phase you will undergo a screening evaluation process designed to identify risk factors that are associated with increased risk for incurring cardiovascular disease.  This will include having you fill out a written medical questionnaire form & an informal interview.  This written & verbal aspect will assist in the evaluation of your overall health.  To compliment these factors, blood pressure, body fat percentage, resting heart rate, height & weight will be determined.

Upon successful completion of the screening phase, you may elect to go through the fitness evaluation phase.  After consultation with your personal trainer/doctor fitness evaluation may or may not be initially encouraged.  The fitness evaluation is certainly not necessary for you to begin an affective, safe & exciting program.  A thorough & honest approach to phase one screening sets the stage for a safe starting point.

Fitness evaluations are not to be confused with medical diagnostics tests.  Their purpose is to evaluate your starting point with regard to current level of fitness, develop an individual exercise program, provide incentive & note progress.

Fitness evaluations can include:

Physical movement screening for muscle/ postural imbalances
Assess flexibility/ mobility
Strength, 1RM test
Muscular endurance
1.5 mile cooper test
Skin folds to measure body fat percentage
Waist to hip ratio
Blood pressure assessment
Step up test

At best, all of these fitness testing procedures are a general measure of your degree of fitness, they DO NOT state whether you have heart disease.  Furthermore you agree to look to your physician/doctor for any medical care.

A short period of time must pass before the appropriate data can be compiled.  At this point a meeting will take place between you & Colin Bell.  All pertinent information will be explained with an accompanying personal exercise plan.

Any questions you have about the procedures risks & benefits to be expected are welcome.  If you have any reservations or doubts, please voice your concerns and ask for an explanation or clarification.

Participation in any test and in this program is voluntary.  You are free to deny consent or withdraw consent after at any time after consenting.  However it is important that you promptly report any unusual feelings and other information that can assist me with any difficulties you perceive or are experiencing.  It is your responsibility to fully disclose such information.

I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in this program and fitness testing procedures may be injurious to my health, am voluntarily participating in Colin Bell’s prescribed training program which has been explained to me verbally and in written form.

Having such knowledge, I hereby release Colin Bell from liability for accidental injury or illness which I may incur as a result of participating in said fitness program or in the testing/screening procedures.  I hereby assume all risks connected therewith and consent to participate in said program.

Signature ___________________________________________Date______________________

 

Exercise Profile

Do you consider yourself:

Sedentary                    Lightly active             Moderately Active                  Highly active

How many minutes per week do you spend exercising?

0                            1-15                             15-30                           30-60

61-90                       91-120                         121-180                       181 & above

Are you currently involved in a regular exercise program?              Yes                  No

Do you regularly walk or run one or more miles continuously?       Yes                  No

If yes, average number of miles covered per workout day_________________

Average time per mile (minutes & seconds) __________    unsure _________

Do you practise weightlifting?

Do you practise calisthenics?

Do you participate in competitive sports?

If yes, what sport & How often ______________________________________________________

What activities would you prefer to participate in during a regular exercise program?

Walking/running                               Skipping                                 Weightlifting

Rowing machine                               Medicine Ball                         Suspension

Stationary bike                                   Kettlebell                               Balance

Cross trainer                                       Powerbag                                Bodyweight exercises

Other, please state ________________________________________________________________________________________________________________________________________________________________

Is there any exercise that you dislike doing?  Please state _________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Why do you want to start an exercise program?

My doctor told me to                 I want to lose weight                     I want to feel good

I want to gain strength              I want to build muscle                  I want to be fitter

Improved Sport Performance

Other

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Medical  Questionnaire

Name______________________________________________________________________

Address____________________________________________________________________

Phone number_______________________________________________________________

Email______________________________________________________________________

Sex
Male                            Female

Date of Birth_____________Age_____________________________________________________

Height_____________________________________________________________________

Weight_____________________________________________________________________

 

Medical History

  1. Has your doctor ever said that your blood pressure is too high/too low? Y         N
  2. Do you ever have pain in your chest or heart? Y         N
  3. Does your heart often race like mad? Y            N
  4. Are your ankles often badly swollen? Y            N
  5. Do you suffer from frequent cramps in your legs? Y         N
  6. Do you often have difficulty breathing? Y         N
  7. Do you sometimes get out of breath when sitting still or sleeping? Y         N
  8. Has your doctor ever told you that your cholesterol was too high? Y         N

Comments

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Do you now have or have you recently experienced:

  1. Chronic, recurrent or morning cough? Y         N
  2. Episode of coughing up blood? Y         N
  3. Increased anxiety or depression? Y         N
  4. Problems with current fatigue? Y         N
  5. Trouble sleeping? Y         N
  6. Migraine or recurrent headaches? Y         N
  7. Swollen, stiff or painful joints? Y         N
  8. Pain in your legs after walking short distances? Y         N
  9. Foot problems? Y         N
  10. Back problems? Y         N
  11. Significant vision or hearing problems?                         Y         N
  12. Glaucoma or increased pressure in your eyes? Y         N

Comments

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Men & Women answer the following.

List any medications you are now taking: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List any self-prescribed medications you are now taking: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List any supplements you are taking: ______________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

 

Heart disease risk factors

Smoking

Have you ever smoked cigarettes, cigars or a pipe?              Yes      No

If you did or now smoke cigarettes, cigars or a pipe, how many per day?

If you stopped smoking, when was it?

If you now smoke, how long ago did you start

 

Alcohol

Do you drink alcoholic beverages?                                        Yes      No

If yes, what is your approximate intake of these beverages:

 

Beer

None               Occasional                  Often               If often, _______________ Per week

 

Spirits

None               Occasional                  Often               If often, _______________ Per week

 

Wine

None               Occasional                  Often               If often, _______________ Per week

 

Diet

Number of meals you eat per day _____________________________________________________

Number of times per week you usually eat the following:

Beef ___________ Fish __________ Desserts__________

Pork ___________ Fowl __________Take away food__________

Confectionery ___________

How many glasses/ litres of water consumed each day?____________________________________

How many fizzy drinks each day?_____________________________________________________

How many cups of coffee/tea each day?________________________________________________

Do you usually take salt with your food?      Yes                  No

Do you take extra sugar?                                Yes                  No

Comments

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