123 PERSONAL TRAIN ME CLIENT PORTFOLIO

Name:
Date:
Age:
DOB:
Street Address:
City/State/ZIP:

Personal Contact Information

Home Phone:
Work Phone:
Cell Phone:
Fax:

May I call you at work if you are not at home when i try to contact you?      

Yes
No  

May I call your cell phone if you are not at home/office?

Yes
No 

E-Mail:

Emergency Contact Information

Name:
Relation:
Telephone: (Day)
Telephone: (Evening)
Street Address:
City/State/ZIP:

Exercise History

What prior exercise experience do you have and how long ago was it?




Please list any physical recreational activities you are involved with:


How did you find out about 123 Personal Train Me?



MEDICAL HISTORY QUESTIONNAIRE

Do you have or have had any of the following medical conditions?

***Please circle all that apply***

Cancer Cirrhosis/Liver Disease
Diabetes Polio
Hypoglycemia Chronic Bronchitis
Hypertension (High Blood Pressure)
Pneumonia
Heart Disease Migraine Headaches
Angina
Anemia
Stroke Stomach Problems (Ulcers)
Kidney Disease
Arthritis


Kidney Stones Gout
Urinary Tract
Visual Problems
Allergies Hearing Problems
Asthma Seizures Disorder
Rheumatic Fever HIV/AIDS
Hepatitis/Jaundice Tuberculosis
Osteoporosis Neurological Condition(s)
Vertigo/Balance Disorder Sciatica/Radiculopathy/Back Pain
Broken/Fractured Bone(s)
Soft Tissue Injury (Sprains/Strains)

*If you have circled any of the listed medical conditions that require additional explanation, please indicate below:

If you are currently being treated for any medical conditions please list them here:

Please list any and all operations you have had:

Do you smoke?

Yes
No  

How many per day & for how many years?

Occupation (This may be important when designing your exercise program):

CLIENT POLICIES AND AGREEMENT


· 24 hours notice is required for all canceled sessions. Unfortunately, there are NO EXCEPTIONS TO THIS CLAUSE! If proper notification is not given, a cancellation fee of $50.00 will be charged. THIS POLICY WILL BE STRICTLY ENFORCED.

· If you wish to reschedule an appointment, 123 Personal Train Me will make every attempt to accommodate your request. However, if we are unable to find an alternative time slot within the same week (weeks run from Monday to Sunday), and your request is placed less than 24 hours prior to your scheduled appointment time, a cancellation fee of $50.00 will be charged.

· Training sessions are 45 mins in length. The session will begin when your trainer arrives at the predetermined meeting place (i.e. your house, outside or gym). If you are not ready at that time or are interrupted during your training session, your designated time will not be extended. Therefore, it is recommended that you prepare in advance for the arrival of your trainer.

· Sessions can be performed in your home, outside or gym).

· In the event that you are not at your predetermined meeting place (i.e. your house, outside or gym) at your scheduled meeting time, your trainer is required to wait 15 minutes past the scheduled meeting time. If after 15 minutes has passed, and you have not shown for your training session, your trainer is permitted to leave and a cancellation fee of $50.00 will be charged.

· A $25.00 fee will be charged for any checks returned to 123 Personal Train Me due to insufficient funds in your bank account.

· Billing Procedure: The total of all sessions booked during any given month will be calculated and billed at the start of that month. For example, if you book a 10-session program for the month of January, you will be billed the first week of January for 10 sessions. A one-week grace period will be granted to submit your payment.

· 123 Personal Train Me reserves the right to not accept a person(s) for training

 

    

 

 

 
 

   
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