Forms
Assessment Form
Date: Gender:
Name : Date of Birth:
Address: Emergency contact NRF:
City: Telephone:
State: Email:
Telephone: Cell Phone:
Please describe your training goals briefly.
What is the main motivating factor behind you joining a training program? How motivated are you because of this factor? (1-5)
Have you been training in the last year? If yes, please describe any improvements in your fitness level?
What part of your current training program do you like the most? Why? The least? Why?
As far as the achievement of your training goals are concerned, how satisfied are you with your current training program (on a scale of 1-4, where 1 is least satisfied)? Why?
If you have a personal trainer, are you satisfied with his/her instruction and/or knowledge? What do you dislike most about the training program or trainer?
Regular exercise is beneficial to the health in general. However, one must be careful about any associated injury or risk. Please fill out the form below carefully so that your training program can be properly planned in accordance with your risk profile. Please answer “Yes” or “No” to the following questions:
1. Do you have a heart condition that limits your activity to that advisable only by your physician? If yes, is a doctor currently prescribing medication for your blood pressure or a heart condition?
2. When you do physical activity do you feel pain in your chest? When you are not doing physical activity, have you had chest pain in the past month?
3. Do you ever loose consciousness or your balance due to dizziness?
4. Do you have a joint or bone problem that may get worse due to physical activity?
5. Do you have insulin dependent diabetes? History of diabetes in the family?
If you answer “Yes” to any one question, please get a medical authorization to undertake training from your physician.
I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction. I understand that I will be voluntarily going through a strenuous physical training routine during which I could get injured, and take full responsibility of any risks due to any injury that might result. I agree to waive any claim or right to sue Advanced Training Techniques, Inc, or any agents, employees, or instructors associated with the training program for injury to myself as a result of the training activity.
_____________________________ _____________ Participant's signature Date