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INFORMED CONSENT
INFORMED CONSENT FOR PARTICIPATION
IN A HEALTH AND FITNESS TRAINING PROGRAM
NAME: _____________________________ _______ DATE: ____________________
1. PURPOSE AND EXPLANATION OF PROCEDURE
I hereby consent to voluntarily engage in an acceptable plan of personal fitness
training. I also give consent to be placed in personal fitness training program
activities which are recommended to me for improvement of dietary counseling,
stress management, and health/fitness education activities. The levels of exercise I
perform will be based upon my cardiorespiratory (heart and lungs) and muscular
fitness. I understand that I may be required to undergo a graded exercise test prior to
the start of my personal fitness training program in order to evaluate and assess my
present level of fitness.
I will be given exact personal instructions regarding the amount and kind of
exercise I should do. A professionally trained personal fitness trainer will provide
leadership to direct my activities, monitor my performance, and otherwise evaluate
my effort. Depending upon my health status, I may or may not be required to have my
blood pressure and heart rate evaluated during these sessions to regulate my exercise
within desired limits. I understand that I am expected to attend every session and to
follow staff instructions with regard to exercise, stress management, and other health
and fitness regarded programs. If I am taking prescribed medications, I have already
so informed the program staff and further agree to so inform them promptly of any
changes which my doctor or I have made with regard to use of these. I will be given
the opportunity for periodic assessment and evaluation at regular intervals after the
start of the program.
I have been informed that during my participation in the above described personal
fitness training program, I will be asked to complete the physical activities unless
symptoms such as fatigue, shortness of breath, chest discomfort or similar
occurrences appear. At this point, I have been advised that it is my complete right to
decrease or stop exercise and that it is my obligation to inform the personal fitness
training program personnel of my symptoms, should any develop.
I understand that during the performance of exercise, a personal fitness trainer
will periodically monitor my performance and, perhaps measuring my pulse, blood
pressure, or assess my feelings of effort for the purposes of monitoring my progress. I
also understand that the personal fitness trainer may reduce or stop my exercise
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H E A L T H A N D F I T N E S S
P R O F E S S I O N A L S ’ A C T I O N G U I D E
program when any of these findings so indicate that this should be done for my safety
and benefit.
I also understand that during the performance of my personal fitness training
program physical touching and positioning of my body may be necessary to assess
my muscular and bodily reactions to specific exercises, as well as to ensure that I am
using proper technique and body alignment. I expressly consent to the physical
contact for the stated reasons above.
2. RISKS
It is my understanding and I have been informed that there exists the remote
possibility during exercise of adverse changes including, but not limited to, abnormal
blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare
instances heart attack, stroke, or even death. I further understand and I have been
informed that there exists the risk of bodily injury including, but not limited to,
injuries to the muscles, ligaments, tendons, and joints of the body. Every effort, I
have been told, will be made to minimize these occurrences by proper staff
assessments of my condition before each personal fitness training session, staff
supervision during exercise and by my own careful control of exercise efforts. I fully
understand the risks associated with exercise, including the risk of bodily injury, heart
attack, stroke or even death, but knowing these risks, it is my desire to participate as
herein indicated.
3. BENEFITS TO BE EXPECTED AND ALTERNATIVES AVAILABLE TO
EXERCISE
I understand that this program may or may not benefit my physical fitness or
general health. I recognize that involvement in the personal fitness training sessions
will allow me to learn proper ways to perform conditioning exercises, use fitness
equipment and regulate physical effort. These experiences should benefit me by
indicating how my physical limitations may affect my ability to perform various
physical activities. I further understand that if I closely follow the program
instructions, that I will likely improve my exercise capacity and fitness level after a
period of 3-6 months.
4. CONFIDENTIALITY AND USE OF INFORMATION
I have been informed that the information which is obtained in this personal
fitness training program will be treated as privileged and confidential and will
consequently not be released or revealed to any person, to the use of any information
which is not personally identifiable with me for research and statistical purposes so long
as same does not identify my person or provide facts which could lead to my
identification. Any other information obtained, however, will be used only by the
program staff to evaluate my exercise status or needs.
5. INQUIRIES AND FREEDOM OF CONSENT
I have been given an opportunity to ask questions as to the procedures.
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I have read this Informed Consent form, fully understand its terms, understand that
I have given up substantial rights by signing it, and sign it freely and voluntarily,
without inducement.
Participant’s Signature
_____________________________________________________________
Participant’s Name (Printed)
_____________________________________________________________
Witness’s Signature ______________________________ Date: ______________
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HEALTH AND MEDICAL QUESTIONNAIRE
ANYFITNESS INC
HEALTH & MEDICAL QUESTIONNAIRE
Name: _________________________ Date of birth: _____________________
Date: ________________
Address:________________________________________________________________
Street City State Zip
Phone (Cell): __________________ (Work): _________________
Email address: ___________________
In case of emergency, whom may we contact?
Name: _________________________ Relationship: _______________________
Phone (Cell):_________________________ (Home):___________________________
Personal physician
Name: _________________________ Phone: _______________________
Fax: __________________
Present/Past History
Have you had or do you presently have any of the following? (Check if yes.)
______ Rheumatic fever
______ Recent operation
______ Edema (swelling of ankles)
______ High blood pressure
______ Low blood pressure
______ Injury to back or knees
______ Seizures
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H E A L T H A N D F I T N E S S
P R O F E S S I O N A L S ’ A C T I O N G U I D E
______ Lung disease
______ Heart attack or known heart disease
______ Fainting or dizziness
______ Diabetes
______ High Cholesterol
______ Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden,
unexpected attack) or nocturnal dyspnea (shortness of breath at night)
______ Shortness of breath at rest or with mild exertion
______ Chest pains
______ Palpitations or tachycardia (unusually strong or rapid beat)
______ Intermittent claudication (calf cramping)
______ Pain, discomfort in the chest, neck, jaw, arms, or other areas
______ Known heart murmur
______ Unusual fatigue or shortness of breath with usual activities
______ Temporary loss of visual acuity or speech, or short-term numbness or weakness
in one side, arm, or
leg of your body
Cancer
______ Other (please describe): __________________________________________
Family History
Have any of your first-degree relatives (parent, sibling, or child) experienced the
following conditions? (Check if yes.) In addition, please identify at what age the
condition occurred.
______ Heart attack
______ Heart operation (Bypass surgery, Angioplasty, Coronary Stent placement)
______ Congenital heart disease
______ High blood pressure
______ High cholesterol
______ Diabetes
______ Other major illness: _____________________________________
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Explain checked items :
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Activity History
1. How were you referred to this program? (Please be specific.)
__________________________________________________________________
2. Why are you enrolling in this program? (Please be specific.)
_________________________________________________________________
3. Have you ever worked with a personal trainer before? Yes _____ No _____
4. Date of your last physical examination performed by a physician:
____________________________
5. Do you participate in a regular exercise program at this time?
Yes _____ No ______ If yes, briefly describe:
__________________________________________________________________
__________________________________________________________________
5. Can you currently walk 4 miles briskly without fatigue? Yes ______ No ______
6. Have you ever performed resistance training exercises in the past?
Yes ______ No _______
7. Do you have injuries (bone or muscle disabilities) that may interfere with
exercising? Yes ______No ______ If yes, briefly describe:
__________________________________________________________________
8. Do you smoke? Yes ______ No ______ If yes, how much per day and what was
your age when you started? Amount per day _______ Age _______
9. What is your body weight now? _______What was it one year ago? ________
At age 21? _______
10. How tall are you?
11. Do you follow or have you recently followed any specific dietary intake plan and,
in general, how do you feel about your nutritional habits?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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12. List the medications you are presently taking.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
13. List in order your personal health and fitness objectives.
a. ____________________________________________________________
b. ____________________________________________________________
c. ____________________________________________________________
d. ____________________________________________________________
Thank you.
Type of physical
activity:
Aerobic Strength
Number of days
per week:
Minutes per day:
Total minutes
per week*:
Minimum of 150 minutes
of moderate physical activity a week (for example, 30 minutes per day,
five days a week) and muscle-strengthening activities on two or more
days a week (
2008 Physical Activity Guidelines for Americans).
For more information, visit www.acsm.org/physicalactivity.
Name:
Phone:
Address:
Web Site:
Follow-up Appointment Date:
Notes:
Type of physical
activity:
Aerobic Strength
Number of days
per week:
Minutes per day:
Total minutes
per week*:
Minimum of 150 minutes
of moderate physical activity a week (for example, 30 minutes per day,
five days a week) and muscle-strengthening activities on two or more
days a week (
2008 Physical Activity Guidelines for Americans).
For more information, visit www.acsm.org/physicalactivity.
Name:
Phone:
Address:
Web Site:
Follow-up Appointment Date:
Notes: