OneLove Fitness
New Client Forms
PLEASE RETURN COMPLETED FORMS 1-888-644-0153 (fax) or
You Lifestyle Coach needs this important information before your appointment. (5 Pages)
Name ______Date ______
DOB ___-___-19__ Address ______City ______Zip ______
Phone number (home) ______(cell) ______
Email address ______Name of Gym you joined ______
When is the best time to contact you? ______
Work schedule Days and times ______
What days of the week and times are best for your session(s)? ______
How many sessions are you interested in purchasing?* *Coach can make a recommendation.
______
Which of the following goals do you have?
____ Gain weight/muscle ____ Increase energy ____ Reduce Stress
____ Improve cardiovascular fitness ____ Rehabilitate injury ____ Improve flexibility
____ Lose weight/inches ____ Improve muscle tone/shape ____ Prevent injury
____ Improve strength ____Sports training ____ What sport? ______
Other (explain) ______
How did you hear about us? ______
CANCELLATION POLICY: We require 24 hour notice for cancellations of your scheduled appointment.
If you are unable to give 24 hours notice, you will be charged $10-30 for the session.
I have read and understand the cancellation policy. (Participants under 18 require a Parents signature please)
Signed: ______Relationship (if under 18) ______
Physical Activity Readiness (PAR–Q) Form
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active everyday. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.
If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age please provide medical clearance from your Doctor along with these forms.
Please read the questions carefully and answer each one honestly: Check YES or NO.
YES / NO / PARQ1. Has your Doctor ever said that you have a heart condition and that you should only do physical activity recommended by a Doctor?
2. Do You feel pain in your chest when you do physical activity?
3. In the past month, have you had chest pain when you were not doing physical activity?
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
6. Is your Doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
7. Do you know of any other reason why you should not do physical activity?
IF YOU ANSWERED:
YES to one or more questions: Talk to your Doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.
- The Doctor will tell if/when you may be able to do any activity you want – as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
NO to ALL questions: If you answered NO honestly to ALL questions, you can be reasonably sure that you can:
- Start becoming much more physically active. Begin slowly and build up gradually. This is the safest and easiest way to go.
Please note: If your health changes so that you then answer YES to any of the above questions or you become pregnant, tell your fitness or health professional. Ask whether you should change your physical, activity plan. Delay activity if you are not feeling well because of cold or fever- wait until you feel better again.
ONELOVE FITNESS WELLNESS HISTORY & STATUS FORM
Name ______Cell ______
Age ______Gender ______Height ______Weight ______Birthday ______
Emergency Contact ______Relation ______Phone ______
Emergency Contact ______Relation ______Phone ______
Physician’s Name ______Phone ______
Are you presently exercising? ______How many hours a week? ______
Briefly describe your exercise program (include days and times): ______
______
______
List any injuries or physical conditions that might affect your ability to exercise:
______
______
List any illnesses, hospitalization, or surgical procedures that you had within the last two years:
______
List any medications you are presently taking, dose, and reason:
______
______
Please list any over-the-counter medications and dietary supplements you are currently taking:
______
Do you have high blood pressure? ______High Cholesterol? ______
Do you smoke? _____ if yes, how much?______Do you want to Quit?______
WAIVER FOR PARTICIPATION:
I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction. I, the undersigned, parent or guardian (if under 18), do hereby agree to allow the individual(s) named herein to participate in the aforementioned activity(s). Further, my family and I agree to indemnify and hold OneLove Enterprises and T’Ronda Flagg Joseph harmless from and against any and all liability for any injury, including death, which may be suffered by the aforementioned individual(s), arising out of or in any way connected with his/her participating in this/these activity(s).
I am signing this waiver freely and voluntarily.
Signature: ______Date ______
ONELOVE FITNESS LIFESTYLE INFORMATION FORM
Name ______Date ______
Physical Activity
In the past year, how often have you been engaged in physical activity?
_____ Regularly (3 to 4 times a week) _____ Semi-regularly (1 to 2 times a week)
_____ Sporadic (1 to 2 times a month) _____ None Length of time ______
What types of physical activity do you consider “fun”? ______
______
What are your personal barriers to exercise (i.e., your reasons for not exercising)?
______
What physical activity have you been successful with in the past that you liked and participated in regularly? ______
______
How do you think your weight affects your daily activities? _____ Does not affect or Explain
______
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Support
Do you feel any family, friends or co-workers have negative feelings (i.e. disapproval, resentment, etc.) towards your efforts at physical activity? ____ No _____ Yes, please explain
______
Is your significant other or a close friend involved in regular physical activity? What activity?
______
Occupation/Leisure
Current occupation? ______
Does your occupation require much activity (ie walking, getting up and down, carrying things)?
______
What are your usual leisure activities? ______
ONELOVE FITNESS LIFESTYLE INFORMATION FORM- Page 2
Stressors
What types of things make you feel stressed? ______
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How do you normally deal with your stress? ______
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Dietary Patterns
Do you eat Breakfast ? _____ Lunch? ______Dinner? ______# of Snacks ______
What would you estimate your caloric intake to be per day? ______
Do you feel you eat healthy “most of the time” ? ______
How much water would you estimate you drink per day? ______
Expectations
Specifically describe what you would like to accomplish through your fitness program during the next:
1 month: ______
______
4 months: ______
______
1 year: ______
______
General information you want us to know: ______
______
______
PLEASE RETURN COMPLETED FORMS 1-888-644-0153 (fax) or
We look forward to meeting you!
OneLove Fitness Management