Train by Trina  Personal Fitness Training, Toronto, Ontario

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Client Medical History

If you would prefer to complete this by hand, please download our Registration Form (PDF) here.

Client Information

Full Name: *
Age: *
Date of Birth: *	(mm/dd/yyyy)
Gender: *	Female Male
Home Phone: *
Cell Phone:
Work Phone:
Email:

Physician Information

Physician Name:
Physician Phone:

Emergency Contact Information

Emergency Contact Name and Relationship:
Emergency Contact Phone:
Emergency Contact Cell Phone:
Emergency Contact Work Phone

Medical Information

Are you currently taking any medications?	Yes No
If so, please list the medication and reason.

Does your physician know that you are participating in an exercise program?	Yes No
What type of physical activity do you do somewhat regularly?

Do you now, or have you had in the past:
History of heart problems, chest pain, or stroke	Yes No
Increased blood pressure	Yes No
Any Chronic illnesses or conditions	Yes No
Difficulty with physical exercise	Yes No
Advice from a physician not to exercise	Yes No
Recent surgery (last 12 months)	Yes No
Pregnancy (now or within the last three months)	Yes No
History of respiratory or lung problems	Yes No
Muscle, joint or back disorders	Yes No
Diabetes or a thyroid condition	Yes No
Cigarette smoking habit	Yes No
Problems with obesity (i.e. more than 20% over healthy weight)	Yes No
Increase blood cholesterol	Yes No
History of the heart problems in your immediate family	Yes No
Hernia, or any condition that may be aggravated by lifting weights	Yes No
Please explain any "yes" answers in the space provided below:

Any Other Comments Regarding Medical

Lifestyle Questionnaire

Physical Activity:

In the past year, how often have you engaged in physical activity? Physical Activity - Regularly (3 to 4 times/week) Physical Activity - Semi-Regularly(1 to 2 times/week) Physical Activity - Sporadic(1 to 2 times /month) Physical Activity - None
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 (liked and participated in regularly)

How do you think your weight affects your daily activities?

Support:

Do you feel any family, friends, or co-workers have negative feelings (i.e. disapproval, resentment) towards your efforts at physical fitness?

Is your significant other involved in any regular physical activity?

Occupation/leisure:

What is your present occupation?

Does your occupation require much activity (i.e. walking getting up and down carrying things)?

What are your usual leisure activities?

Stressors:

What type of things make you feel stressed?

How do you deal with your stress normally?

Dietary Patterns:

In the space below please provide a brief example of types of meals/snacks taken in during the day - include beverages
Breakfast
Morning Snack
Lunch
Afternoon Snack
Dinner
After Dinner Snack
Do you feel you eat healthy "most of the time"? Yes No

Expectations:

Specifically describe what you would like to accomplish through your fitness program during the next:
1 Month
3 Months
6 Months
What do you expect to gain from having a trainer?

Realistically how many hours a week do you have to exercise (including the time you spend with me)?

Do you like being left with activities that you can do on your own?

Any Other Comments Regarding Lifestyle :

PAR-Q and You

(A Questionnaire for People Aged 15 to 69)

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. 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, 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: check YES or NO.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?	Yes No
Do you feel pain in your chest when you do physical activity?	Yes No
In the past month, have you had chest pain when you were not doing physical activity?	Yes No
Do you lose your balance because of dizziness or do you ever lose consciousness?	Yes No
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?	Yes No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?	Yes No
Do you know of any other reason why you should not do physical activity?	Yes No
"I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction." Initials: *

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 which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

Find out which community programs are safe and helpful for you.

If you answered NO to all questions

If you answered NO honestly to all PAR-Q 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.
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. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.

Delay becoming much more active:

if you are not feeling well because of a temporary illness such as a cold or a fever - wait until you feel better; or
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, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity.

Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.

Package selection and payment options

	One Session Personal Training $80.00
	10 Pack of Personal Training Sessions $750.00
	20 Pack of Personal Training Sessions $1400.00

Registration Policies

We accept payment on-line with VISA or MasterCard via PayPal, or you may bring payment in full in either cash or a cheque payable to Train by Trina prior to the start of your first session.

There is a $20.00 charge for NSF cheques.

How would you like to pay?:*

PayPal
Cash or Cheque

Personal Training Cancellation Policy

Cancellation must be made to Trina via phone (416 788 2535) or email (merchandise@trainbytrina.com) 24hr's in advance. At that time we will make arrangements to make up that appointment so you don't get off track!!

If 24hr notice is not given that session will be deducted from your package.

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