All information given is personal and kept confidential.
Client Information
Name:
Date:
Age:
Date of Birth:
/
Address:
/
Height:
Weight:
City/State:
Cell Phone:
Zip Code:
Email:
Signs and Symptoms
Have you ever experienced any of the following: (please check yes or no)
Yes
No
1. Pain, discomfort, tightness or numbness in the chest, neck, jaw, or arms.
2.
Shortness of breath at rest or with mild exertion
3.
Dizziness or fainting
4.
Difficult, labored, or painful breathing during the day or at night.
5.
Ankle Swelling.
6.
Rapid pulse or heart rate at rest or with mild exertion.
7.
Intermittent cramping.
8.
Known heart murmur.
9.
Unusual shortness of breath or fatigue with usual activities.
If you answered yes to any of the above:
How often do you experience the symptom?
Have you ever discussed the symptom with a doctor?
Explain the symptom in more detail:
Major Risk factors
Yes
No
1.
Do you have a body mass index of > 30 or a waist girth > 100 cm (39.3 inches)?
2.
4.
Have you had a fasting glucose of > 110 mg/dl confirmed by measurements on at least two
separate occasions?
Has your father or brother experienced a heart attack before the age of 55? Or has your mother or
sister experienced a heart attack before the age of 65?
Do you currently smoke, or have quit within the past 6 months?
5.
Has your doctor ever told you that you have high blood pressure?
6.
Do you have high cholesterol?
Total cholesterol:
HDL:
LDL:
Date tested:
Do you have a sedentary lifestyle? (Sitting most of the day in your job with no regular physical
activity?)
3.
7.
Medical Diagnoses
Have you ever experienced any of the following? Please mark all that apply:
Anemia
Cancer
Emphysema
Osteoporosis
Angina
Coronary Artery Disease
Heart Attack
Blood clots
Angioplasty
Diabetes
Heart Murmur
Stroke
Arthritis
Eating Disorders
Heart Surgery
Asthma
Emotional Disorders
Hernia
Bronchitis
Hypertension
Embolism (blockage in
an artery)
Any special problems not listed above:
If any of the above are marked, please explain and be detailed:
General Questions
Yes
No
1.
2.
Are you pregnant?
Do you have arthritis or any bone or joint problems?
If yes please explain:
3.
Do you currently exercise?
If yes, how long have you been exercising?
If yes, how often do you exercise?
What type of activities do you do?
4. Are you taking a medications, vitamins, or supplements?
Drug name/dosage of drug/prescribed or over the counter:
PAR-Q (Physical Activity Readiness Questionnaire) Medical Status
Being more active is very safe for most people. However, some people should check with their doctor before they start
becoming more active. If you are planning to become much more physically active, start by answering the seven
questions in the box below. If you are between the age of 15 and 69, PAR-Q will tell you if you should check with your
doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.
Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each
one honestly. Place a check in the space to the left of the question to answer either “Yes” or “No.” Please ask if you have
any questions. Your responses will be treated in a confidential manner.
YES
NO
1.
2.
3.
4.
5.
6.
7.
Has your doctor ever said that you have a heart condition and that you should only do
physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Is your doctor currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition
Do you have a bone or joint problem that could be made worse by a change in your
physical activity?
Do you know of any other reason why you should not do physical activity?
If you answered YES to one or more questions, talk with 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. 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 that are safe for you. Talk with your doctor about the
kinds of activities you wish to participate in and follow his/her advice.
If you answered NO honestly to all questions, y ou 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.
Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the
best way for you to live actively.
Even if you answered no to all questions, you should delay becoming much more active:


If you are not feeling well because of temporary illness such as a cold or fever – wait until you feel better.
If you are or may be pregnant – talk to your doctor before you start becoming more active.
Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health
professional. Ask whether you should change your physical activity plan.
Informed use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for persons who
undertake physical activity. If in doubt after completing this questionnaire, consult your doctor prior to physical activity.
I have read, understood and completed the questionnaire. Any questions I had were answered to my full satisfaction
Name: ____________________________________________
Signature: _________________________________________
Date: __________________________
Personal Training – Indiana University Campus Recreational Sports
INFORMED CONSENT
General Personal Training Program information:
Fitness Assessment
In order to determine my level of physical fitness and capacity for exercise, I hereby consent to engage voluntarily in an
exercise assessment to evaluate the condition of my heart, lungs, and general cardiorespiratory fitness. This test will
continue until symptoms of fatigue, shortness of breath, or chest discomfort appear or the test has been completed.
During the performance of the test, a trained observer will keep me under close surveillance by monitoring my heart rate
and blood pressure. There exists a possibility of certain changes occurring during the test. They include abnormal blood
pressure, fainting, disorders of heartbeat (too rapid, too slow, or ineffective), and very rare instances of heart attack and
death. I understand that every effort will be made to determine and minimize problems by preliminary examination and by
observation during testing. I also understand that trained personnel will be available to deal with unusual situations that
may arise. I recognize that I can discontinue participation at any point during the assessment without penalty of any kind.
I also consent to engage in assessments that will determine my level of body fat, muscular endurance/strength, and
flexibility. The information obtained in this test will assist in recommending the physical activities in which I may safely
engage.
If you purchased a fitness assessment, please initial here_________
Personal Training
I realize that I will participate in physical activity including cardiorespiratory, resistance, and flexibility training/exercise. I
understand that fitness activities involve a risk of injury and even death and that I am voluntarily participating in these
activities and using equipment with knowledge of the dangers involved. I hereby agree to expressly assume and accept
any and all risks of injury and death. As well, knowing that I may participate at my own pace, and that I am free to
discontinue participation at any time, I will inform my personal trainer of any problems immediately.
If you purchased a personal training package, please initial here_________
Personal Training Program
Relative to the fitness testing and personal training, I declare myself to be physically sound and suffering from no
condition, impairment, or disease that would prevent my participation or use of equipment except as hereinafter stated. I
do hereby acknowledge that in order to decrease any risk of injury, I will be required to provide confidential medical history
information about myself and family and may need a physician’s approval for my participation in the aforementioned
activities. I also acknowledge that I should have a yearly or more frequent physical examination and consultation with my
physician as to physical activity and the use of exercise equipment. I acknowledge that I have either had a physical
examination and been given my physician’s permission to participate or that I have decided to participate in activity and
use of equipment without the approval of my physician and do hereby assume all responsibility for my participation and
use of exercise equipment. I certify that I assume and will pay my own medical and emergency expenses in the event of
an accident, illness, or other incapacity, regardless of whether I have authorized such expense.
In consideration of being allowed to participate in the Personal Training Program and to use the facilities and equipment of
Recreational Sports, I do hereby waive, release and forever discharge the Division of Recreational Sports at Indiana
University and its officers, agents, employees, representatives, executors, and all others from any and all responsibilities
or liability from injuries or damages resulting from my participation in any activities, or my use of equipment in the above
mentioned activities.
Please initial here_________
Personal Training Program policies:

Set-Up time – The total time for client-trainer set up is generally two to three business days. If you need a
physician’s clearance, your total set-up time will depend on how quickly the physician’s office responds to our
inquiry. In the case of a physician’s referral, you will be notified via e-mail of your status as soon as the clearance
form is returned.

Trainer Consultation – A 30 minute consultation with your trainer is a required part of each personal training
package (except for renewals). This consultation is not counted against the total number of sessions (hours) you
purchase.

Session length – The sessions you purchase are representative of the total number of hours that you have with
your trainer. The session length is up to you with the input from your trainer. Your sessions purchased can be
broken down to 30, 45, or 60 minutes depending on your goals and what you and your trainer wish to accomplish
during that session.

Late Policy – Trainers are obligated to wait only 15 minutes for clients. After 15 minutes have passed, the trainer
is not required to lead the session, and half of an hour may be deducted from your package. Sessions starting
late will still be completed one hour from the original, scheduled start time.

Cancellation notice – You are asked to call your trainer or Member Services at 855-7772 at least 1 hour before
the scheduled training session if you anticipate a cancellation. Failing to give this amount of notice will result in
half of an hour being deducted from your package.

Package expiration – Packages of 3, 6, or 8 sessions will expire three months from the date of purchase.
Packages of 10, 12, and 16 will expire six months from the date of purchase. The 32 session package will expire
one calendar year from date of purchase. In the case of an extended absence from campus, your package’s
lifecycle will be paused until you return however Spring Break, Thanksgiving Break, and Winter Break are not
considered extended absences.

Nutritional Guidance – Nutritional guidance to assist you in reaching your health, performance, and body
composition goals will be included on any package of 10 sessions or more. You have the right to decline
engagement in any part of the program including the nutritional guidance portion. Nutritional guidance will not be
included on packages of 8 sessions or fewer.

All packages are non-refundable. Extenuating circumstances will be considered by the Assistant Director of
Fitness/Wellness.

Package Renewal – Packages and sessions must be paid in full prior to training. Upon completion of a
package, if you would like to continue training you must purchase a new package before resuming
training. Sessions cannot be rendered without payment.
Participant’s Name (printed)_______________________________
Participant’s Name (signed)____________________________________Date_________________________