Personal Training Health Screening Questionnaire
ASSESSMENT QUESTIONNAIRESTRICTLY PRIVATE AND CONFIDENTIALPersonal Training Health Screening QuestionnairePersonal InformationToday’s date:Title:O DR. O Mr. O Mrs. O Ms.Birth date:Name:First NameLast NameAge:Address:Phone: (Home)City:Phone: (WorkEmail:Phone: (Mob)Occupation:Gender: MaleFemaleHeight:Weight:Blackler Personal Training www.blacklerpersonaltraining.co.uk 07925 062 936Please return completed form to adam@blacklerpersonaltraining.co.uk
ASSESSMENT QUESTIONNAIREPerson to contact in case of emergency:STRICTLY PRIVATE AND CONFIDENTIALTel:Medical HistoryPlease indicate if any of these statements apply to you by placing YES in the space provided(* past or current):1. History of heart problem (i.e. Chest pain, heart murmur, or stroke)2. Diabetes Mellitus3. Asthma, breathing, or lung problems4. Allergies5. Cancer (other than skin)6. Seizures, seizure medication, neurological problems, dizziness7. High blood pressure8. Back problems, joint or muscle disorder still affecting you9. Recent surgery (last 12 months)10. Hernia or any condition that may be aggravated by exercise11. Physician’s advice not to exercise12. History of high cholesterol13. Family history of coronary heart disease?14. Do you smoke tobacco products?15. Do you consume alcohol?16. Do you take supplements of any kind?17. Are you on medication?18. Do you have joint problems that might be aggravated by exercise?19. Is stress from daily living an issue in your life?Blackler Personal Training www.blacklerpersonaltraining.co.uk 07925 062 936Please return completed form to adam@blacklerpersonaltraining.co.uk
ASSESSMENT QUESTIONNAIRESTRICTLY PRIVATE AND CONFIDENTIALSkeletal uriesSurgeriesPlease describe any special considerations or how your injury currently affects your ability tofunction: (i.e. Illness or Injury)Please talk with your doctor by phone or in person before you start any new training programor have a fitness assessment. Tell your doctor about your health questionnaire and whichquestions you answered yes.Goals1. What are your concerns and goals? 9 example: fat loss, strength, power, muscularendurance, cardio fitness, flexibility, agility, core stability or balance)2. Why do you want to achieve these goals? (Examples: general health, injuryprevention/rehab, sport –specific training, aesthetic reasons)Blackler Personal Training www.blacklerpersonaltraining.co.uk 07925 062 936Please return completed form to adam@blacklerpersonaltraining.co.uk
ASSESSMENT QUESTIONNAIRESTRICTLY PRIVATE AND CONFIDENTIAL3. What areas do you want to concentrate on or emphasize? (i.e. specific areas to strengthen,joint stability, cardio or core conditioning)Fitness History4. How long has it been since you have exercised regularly? (2 or more times/week).5. Do you have experience with free weights or functional stability training?6. What type of cardiovascular exercise are you familiar with?7. If you are an experienced exerciser or athlete, what exactly is your currentprogram?8. Are there any exercises that are contraindicated or not recommended by your physician orphysical therapist?9. How would you describe your level of daily activities? Please check one.Light (office work) Moderate( Manual labor) Heavy (construction)10. Stress (high 5, low 1) please circle one.Physical 1 2 3 4 5 Personal/ Emotional 1 2 3 4 5 Mental/Career 1 2 3 4 511. Present method of handling stress:12. Number of hours of sleep per night?Blackler Personal Training www.blacklerpersonaltraining.co.uk 07925 062 936Please return completed form to adam@blacklerpersonaltraining.co.uk
ASSESSMENT QUESTIONNAIRESTRICTLY PRIVATE AND CONFIDENTIAL13. What is your available time and frequency for exercise?What days: M T W TH FWhat times: AMPM14. Any special considerations or requests?Blackler Personal Training www.blacklerpersonaltraining.co.uk 07925 062 936Please return completed form to adam@blacklerpersonaltraining.co.uk
ASSESSMENT QUESTIONNAIRESTRICTLY PRIVATE AND CONFIDENTIALPersonal Training AgreementInformed Consent & Assumption of Risk(Must be signed prior to beginning personal training sessions)I, the undersigned, being aware of my own health and physical condition, and having knowledge that myparticipation in any Blackler Personal Training program may cause injury, am voluntarily choosing to participatein the program. There are always certain risks associated with any physical activity. I understand these risks anddeclare myself physically sound and capable to participate in the program offered through Blackler PersonalTraining.Personal Training Policies and Procedures1. Session or package of sessions are non-refundable and non-transferable2. Session or sessions must be paid in full and will be scheduled with Adam Blackler3. Clients must give 24 hours advanced notice of cancellation. Less than 24 hours or a no-show will result in acharged to the session or package.4. Health Screening / Medical History Questionnaire, and Personal Information forms have been filled outhonestly and to the best of my ability.Print NameSignatureDateBlackler Personal Training www.blacklerpersonaltraining.co.uk 07925 062 936Please return completed form to adam@blacklerpersonaltraining.co.uk
Microsoft Word - ABT-Health-Questionnaire
2 Questionnaire survey Survey research Rossi, P. H., et al. (2013). [4] 3 Questionnaire design A split questionnaire survey design Raghunathan, T. E., et al. (1995). [5] 4 Questionnaire design Designing a questionnaire Ballinger, C., et al. (1998). [6] 5 Questionnaire design Questionnaire design: the good, the bad and the pitfalls.
4.4 Emerging and re-emerging infections 43 4.5 Clinically insignificant transfusion-transmissible infections 44 5 Blood screening, quarantine and release 45 5.1 Blood screening process 45 5.2 Approaches to blood screening 45 5.3 Pooling for serological assays 47 5.4 Sequential screening 47 5.5 Blood screening and diagnostic testing 48 5.6 Emergency screening 48 5.7 Screening plasma for .
Designer Tool: Questionnaires Questionnaire(s) can be sourced from following three ways; my questionnaire (private) -only user that created can see it; questionnaire shared with me - private questionnaire that can be seen by other authorized users; public questionnaire -any user of Survey Solutions can see the questionnaire (not data) And create your survey questionnaire;
Running a Resume Screen Page 2 of 17 version 1.2 (updated 6/11/21) Note: If there were screening levels before the Resume Screening (Online and/or Manual Screening), all screening must be complete prior to running the Resume Screening. 1. Go to the Applicants tab within the Job Opening. 2. If the Resume Screen is the only screening level,
// COMPLETE HEALTH ASSESSMENT – DEVELOPMENTAL SCREENING TOOLS Developmental Screening Tools: Ages and Stages Questionnaire (ASQ) Ages and Stages Questionnaire: Social-Emotional (ASQ-SE) Battelle Developmental Inventory Screening Tool, 2ND ed (BDI-ST) Child Development Inventory (CDI) Denver Developmen
Questionnaire design and analysing the data using SPSS page 1 Questionnaire design. For each decision you make when designing a questionnaire there is likely to be a list of points for and against just as there is for deciding on a questionnaire as the data gathering vehicle in the first place. Before
Pre-Exercise Questionnaire . Today's date: Names of family members or friends already training with us (if applicable): . personal training? Physical fitness. Weight maintenance Weight loss. 0 - 5 kg 20 kg. 10 - 20 kg 5 - 10 kg. Health . the reason you are training Important - necessary for training satisfaction Desirable - an asset to aim .
Wellness Screening and the Healthy Living Wellness Questionnaire. The information you get will help you identify small changes you can make to help you be a little bit better every day—for all the roles you play. Healthy Living Wellness Screening (WS). The WS measures your "health numbers": cholesterol,
