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
- Has your doctor ever said that your blood pressure is too high/too low? Y N
- Do you ever have pain in your chest or heart? Y N
- Does your heart often race like mad? Y N
- Are your ankles often badly swollen? Y N
- Do you suffer from frequent cramps in your legs? Y N
- Do you often have difficulty breathing? Y N
- Do you sometimes get out of breath when sitting still or sleeping? Y N
- Has your doctor ever told you that your cholesterol was too high? Y N
Comments
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you now have or have you recently experienced:
- Chronic, recurrent or morning cough? Y N
- Episode of coughing up blood? Y N
- Increased anxiety or depression? Y N
- Problems with current fatigue? Y N
- Trouble sleeping? Y N
- Migraine or recurrent headaches? Y N
- Swollen, stiff or painful joints? Y N
- Pain in your legs after walking short distances? Y N
- Foot problems? Y N
- Back problems? Y N
- Significant vision or hearing problems? Y N
- 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
