Personal Training Intake Form

Let's Get Started! (New clients please fill out and submit forms #1 & #2.)

Please fill out this Intake Form with the most accurate information possible. We require photos and videos as a submission for a quick posture and physical analysis. Please take photos and videos standing, full body visible with clothing that is not too baggy so that analysis will be easy to conduct.

PLEASE BE SURE TO FILL OUT THIS FILLABLE PARQ+ FORM FIRST AND SAVE IT BECAUSE YOU WILL NEED TO UPLOAD IT WITH FORM #1! AS IT IS A REQUIRED DOCUMENT! MAC COMPUTERS & PHONES, PLEASE DOWNLOAD DOCUMENT TO PHONE AND USE AUTOFILL OPTIONS. YOU CAN ALSO PRINT, FILL AND SCAN THE PDF TO UPLOAD IN FORM #1! THANK YOU! CLICK THE DOCUMENT ICON TO DOWNLOAD!

PARQ+ 2024

CBalance PT Client Intake & PAR-Q Form #1

First name

Last name

Address

Phone

Date of birth

Resting HR

Resting BP

Weight (lbs)

Height (inches)

Health Care Professionals - Check any from which you have regular treatment. Check all that apply.

Where checked, indicate R or L joint and a brief description of injury or pain.

*Indicate additional details and/or medication lists pertaining to the check marked items:

Personal Health History - Fitness & Exercise Questions:

What is your exercise experience?

Have you exercised consistently in the past 3 months?

If you answered yes, please describe the strength & cardio components to date:

Cardio

Strength

Functional/Sport or Occupation-specific conditioning

List details about training programming such as days, sets and reps of exercises.

How long have you been consistently active?

What, if anything, stopped you in the past?

How many hours per week do you have to dedicate to your carry out your training program? (This does not mean time spent with Trainer but rather time available)

What would you rate your current fitness level?

Have you worked with a trainer before?

If yes, how long ago and what type of training did you pursue?

List your fitness goals:

Personal Health History - Nutrition Questions:

What would you rate your current nutrition intake?

How many times a day do you usually eat?

Do you skip meals?

What meals do you skip and why?

How many glasses of water do you consume daily?

Do you feel drops in energy daily? If so, when?

Do you know how many calories you consume daily? If so, how many?

Are you currently/have ever taken a multivitamin or other food supplements? If so, please list:

At work, do you usually:

How many times weekly do you eat out?

Do you do your own grocery shopping and cooking?

Besides hunger, what other reason(s) do you eat?

Do you eat past the point of fullness?

Do you eat foods with high fat & sugar content?

Do you drink alcohol? If so, how much?

Do you have any food allergies or intolerances? If so, please list:

Do you have any digestive concerns? If so, please list:

PAR-Q & Activity Questionnaire

As a fitness participant enrollee, we are legally required to have all active clients fill out and submit a current and accurate PAR-Q+ questionnaire.

The link below will bring you to a PDF form which is fillable online and downloadable. Please upload a completed version of your PAR-Q+ here.

https://eparmedx.com/wp-content/uploads/2023/12/PARQPlus2024Fillable.pdf

Upload your completed PAR-Q+ documentation here:

Personal Training Informed Consent Waiver:

As an enrolled 'Personal Training Client' of CounterBalance Conditioning & Fitness Inc., I do hereby consent to participate in CounterBalance Conditioning & Fitness Inc’s Personal Training, Nutrition and Fitness Testing Sessions that will include cardiovascular exercise, flexibility, weight training, fitness progress counselling and nutrition consultation sessions and diet design including current and accurate nutritional advice to be used voluntarily.

I have been informed and understand that physical exercise has been associated with certain risks, including but not limited to musculoskeletal injury, spinal injuries, abnormal blood pressure responses, and, in rare instances, heart attack or even death. Every effort will be made to minimize these risks.

I, the client, have been informed, understand and am aware that the nutritional advice given during nutrition sessions is current and accurate nutritional information. I am voluntarily using the nutritional advice given during sessions and have full knowledge, understand and appreciate the dangers that can occur with improper use of nutritional information.

Any information that is obtained pertaining to my personal health history, my fitness level and my progress will be treated as privileged and confidential and will not be released or revealed to any person other than select staff aligned with the operations of CounterBalance Conditioning Inc.'s programming, my physician, healthcare practitioner or the program's Supervisor (for record keeping purposes) without my expressed written consent.

I have read and understand the foregoing consent to participation in said program. I am aware that I may discontinue participation in the program at any time that I see fit to do so. If at any time I have questions concerning the content, policies, or procedures regarding these Personal Training Sessions, Nutrition Sessions, or Fitness Appraisals I will discuss these questions with my instructor or the program supervisor immediately.

In addition, I agree to the following: assume all risk of injury and all risk of damage to or loss of property arising out of my participation in this programming information; that all PAR-Q and Health information I have provided is accurate and true; that all appointments are time-specific and cancellation of appointments requires a 24 hour advanced notice or this will result in a LOSS OF SESSION.

I release, discharge, and waive any and all responsibility of CounterBalance Conditioning & Fitness Inc, Amy J. Gallant, and its employees/affiliates from and against any liability of injury, including death, for damage to or loss of property which may be suffered by the undersigned arising out of, or in any way connected with the participation in this program; and indemnify and hold harmless CounterBalance Conditioning & Fitness Inc, Amy J. Gallant, and its employees/affiliates from and against all liability, claims, demands, actions, loss, and damage arising out of my participation in said Personal Training Programming/Online Coaching/Nutrition Consultation Sessions.

Confirm with your initials you agree with and understand the previously written statements:

Release Form & Exclusivity Agreement

This conditioning package includes nutrition consultations, exercise/specific program development and appointments exclusive to CounterBalance Conditioning & Fitness Inc. and is intended solely for the undersigned client. The client shall not photocopy, screenshot, share or redistribute said package contents (programming, information or diet) with any other parties, private or public.

CounterBalance Conditioning & Fitness Inc. reserves all rights to the intellectual property and information provided in this package and redistribution of this specific information is STRICTLY PROHIBITED by law. Doing so will have legal implications and legal action will be taken on the part of CounterBalance Conditioning & Fitness Inc. for this offence. This does not include other information included such as public articles intended for redistribution, general scientific knowledge/theories and general health information and/or facts which may or may not be included over the course of the training package.

By signing this agreement, you acknowledge and consent you are doing so with the sole intent for it to use this release of information for your own individual use and it is not to be shared, photocopied, screenshot, or electronically redistributed in any form.

Confirm with your initials you agree with and understand the previously written statements:

I hereby confirm that all info submitted on this form is accurate and current. I allow CounterBalance Inc. to use my photos for analysis and for future marketing (with my written permission only).

Signature

Posture & Gait Analysis

Please submit pictures and/or movement screens as requested. Please wear non-baggy clothing where the body's dimensions can easily be seen and assessed for posture & movement analysis. See video for overhead squat demo.