ISSA Client Intake Forms
ISSA Client Intake Forms
ISSA Client Intake Forms
NAME: ________________________________________________________________________________
ConfidentialityAgr_1110
International Sports Sciences Association
PLEASE DISCUSS THE FOLLOWING WITH ALL NEW CLIENTS AT YOUR FIRST MEETING
Why did you respond to our advertisement? i) If you could improve or change all these things,
a) What were you curious about? what would it mean to you?
b) What do you think we do? j) How would it impact your feelings of self worth?
c) Why would you be interested in that? k) Do you think you deserve to be fulfilled in this
area of your life?
d) Ideally, what would you like us to do for you?
e) Why is that important?
What is your current fitness program?
a) Exercises:
f) How would it change your life?
b) Nutrition and supplementation:
Let me start out by giving you our definition
c) What do you know about how to improve your
of fitness. conditioning?
a) Experiencing abundant physical health.
How well is your current fitness program
b) Absence of pain, discomfort, illness, and disease.
working for you?
c) Experiencing vitality and high energy, sufficient to
a) Why isnt it working?
enable one to do what one wants.
b) Are you willing to make some changes?
d) Looking attractive and fit, proud of ones appear-
ance. c) Do you care enough about your own well-being
to make it a priority?
e) Capable of living a long, healthy life.
f) Able to participate in sports and active recreational Aside from financial cost, is there anything
activities. that would stop you from embarking on a
g) Having a healthy emotional and mental outlook fitness program?
fostered by the foundation of feeling good. (Overcome all non-cost objections before proceeding.)
Do you agree with this definition? If you had everything you wanted in life
Is there anything you would add or delete? except for good health, would that be
satisfactory?
What is the current state of your fitness?
a) How much do you pay for medical insurance?
a) On a scale of 0-10 with 0 being barely alive and 10
b) How much do you pay for doctor bills?
being totally fit, how do you rate your fitness?
c) Given the expensive cost of health care after one
b) What illnesses or medical conditions do you have?
gets sick, doesnt it make sense to you to spend
c) How is your energy level? a little money to prevent health problems?
d) How would you rate the quality of your nutritional d) How much is your health worth?
intake?
If there were an affordable program that
e) Do you feel refreshed and energized after sleep?
could give you everything you want in the
f) Is your sex life fulfilling? (Dont ask this of clients of the way of health and fitness, would you do it?
opposite sex as it may be misconstrued.)
When?_____________ (If they are not willing to act now,
g) What areas of your personal fitness would you like
you should terminate interview at this point and ask them to come
to improve?
back when they are ready to make a change.)
h) What specific thing would you like to change?
What else?
What else?
continued on back
Intake_0805
International Sports Sciences Association
PLEASE DISCUSS THE FOLLOWING WITH ALL NEW CLIENTS AT YOUR FIRST MEETING
Okay (Name), let me tell you a little about my expe- At the end of the introductory session, well make a
rience and my personal philosophy of fitness. In work- decision as to whether you should become my regu-
ing with clients, I like to focus on... (expand). I have lar client or not. If the decision is no well just part
lots of experience in... (expand on your areas of as friends. If its yes, Ill ask you to commit to a series
expertise). Most of my clients are able to achieve their of sessions and well carefully define your goals and
goals because... (expand on your motivational skills). make sure that you reach them. Does that sound fair
Another reason for my high success rate is that I con- to you? (Yes.)
fine my practice to only those individuals who are Good. What time of the day works best for you for the
really serious about improving their fitness. Are you? sample session morning, afternoon, or evening?
(Answer.) (Answer) Okay, I have two time slots open this week.
Okay (Name), the next step is to set up an introduc- (Tuesday at one oclock or Wednesday at two oclock)
tory session so that we can get a feel for how effec- Which is better for you? (Choice.) Great, then Ill see
tively we can work together. The session will last for you at (time). (While shaking hands enthusiastically...)
forty-five minutes and the cost is just $. Its been a pleasure meeting you.
Notes:
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 physi-
cally 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 to 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.
YES NO
q q 1. Has your doctor ever said that you have a heart condition and that you should only do
physical activity recommended by a doctor?
q q 2. Do you feel pain in your chest when you do physical activity?
q q 3. In the past month, have you had chest pain when you are not doing physical activity?
q q 4. Do you lose your balance because of dizziness or do you ever lose consciousness?
q q 5. Do you have a bone or joint problem (for example, back, neck, knee, or hip) that
could be made worse by a change in your physical activity?
q q 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition?
q q 7. Do you know any other reason why you should not do physical activity?
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 completion of this questionnaire, consult your doctor prior to physical activity.
NOTE: If the PAR-Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section may be used for legal
or administrative purposes.
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.
NAME: _____________________________________________________________________________
NOTE: This physical activity clearance is valid for a maximum of 12 months form the date it is completed and
becomes invalid if your condition changes so that you would answer YES to any of the seven questions.
ParQ_0805
International Sports Sciences Association
Address:
Employer: Occupation:
Have you ever had angina pectoris, sharp pain, or heavy pressure in your chest as a result of exercise, Yes No
walking, or other physical activity such as climbing stairs? (Note: This does not include the normal out
of breath feeling that results from normal activity)
Do you experience any sharp pain or extreme tightness in your chest when you are hit with a Yes No
cold blast of air?
Have you ever experienced rapid heart action or palpitations? Yes No
Have you ever had a real or suspected heart attack, coronary occlusion, myocardial infarction, Yes No
coronary insufficiency, or thrombosis?
Have you ever had rheumatic fever? Yes No
Does anyone in your family have diabetes, hypertension, or high blood pressure? Yes No
Has more than one blood relative (parent, sibling, first cousin) had a heart attack Yes No
or coronary artery disease before the age of 60?
Have you ever taken medications or been on a special diet to lower your cholesterol? Yes No
Have you ever taken digitalis, quinine, or any other drug for your heart? Yes No
Have you ever taken nitroglycerine or any other tablets for chest paintablets Yes No
you take by placing under the tongue?
Please note: possession of this form does not indicate certification status with the ISSA. To confirm active certification status, please call 1.800.892.4772 (1.805.745.8111 international). Information gathered from
this form is not shared with ISSA. ISSA is not responsible or liable for the use or incorporation of the information contained in or collected from this form. Always consult your doctor concerning your health,
Screen_0805
diet, and physical activity.
International Sports Sciences Association
Grams
Time Food and Amount
Protein Carbs Fat
Please note: possession of this form does not indicate certification status with the ISSA. To confirm active certifica-
tion status, please call 1.800.892.4772 (1.805.745.8111 international). Information gathered from this form is not TOTAL
shared with ISSA. ISSA is not responsible or liable for the use or incorporation of the information contained in or
collected from this form. Always consult your doctor concerning your health, diet, and physical activity.
DietaryWS_0805
GRAM GOAL
International Sports Sciences Association
In which of the following high school or college athletics did you participate?
None Track
Football Swimming
Basketball Tennis
Baseball Wrestling
Soccer Golf
Other:________________________
NAME: ________________________________________________________________________________
BENEFITS
Participation in a regular program of physical activity has been shown to produce positive changes in a number of
organ systems. These changes include increased work capacity, improved cardiovascular efficiency, and increased
muscular strength, flexibility, power and endurance.
RISKS
I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and the cardiorespirato-
ry system (dizziness, discomfort in breathing, heart attack). I hereby certify that I know of no medical problem
(except those noted below) that would increase my risk of illness and injury as a result of participation in a regular
exercise program.
NAME: ________________________________________________________________________________
Please note: possession of this form does not indicate certification status with the ISSA. To
InformedConsent_0805
confirm active certification status, please call 1.800.892.4772 (1.805.745.8111 international).
Information gathered from this form is not shared with ISSA. ISSA is not responsible or
liable for the use or incorporation of the information contained in or collected from this
form. Always consult your doctor concerning your health, diet, and physical activity.
International Sports Sciences Association
Please indicate in the space provided if you have a history of the following:
1. Heart attack YES NO
2. Bypass or cardiac surgery YES NO
3. Chest discomfort with exertion YES NO
4. High blood pressure YES NO
5. Rapid or runaway heartbeat YES NO
6. Skipped heartbeat YES NO
7. Rheumatic fever YES NO
8. Phlebitis or embolism YES NO
9. Shortness of breath w/ or wo/exercise YES NO
10. Fainting or light-headedness YES NO
11. Pulmonary disease or disorder YES NO
12. High blood fat (lipid) level YES NO
13. Stroke YES NO
14. Recent hospitalization for any cause YES NO
List specifics:
FOR ANY OF THE CONDITIONS CHECKED ABOVE, PLEASE LIST THE DIAGNOSIS AND EXAMINING PHYSICIAN:
GenericFit_0805
International Sports Sciences Association
Address:
Employer: Occupation:
Name: Relationship:
Address:
MEDICAL INFORMATION
Physician: Phone:
Are you under the care of a physician, chiropractor, or other health care professional for any reason? Yes No
If yes, list reason:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Has your doctor ever said your blood pressure was too high? Yes No
Has your doctor ever told you that you have a bone or joint Yes No
problem that has been or could be made worse by exercise?
HealthHistory_0805
International Sports Sciences Association
Is there any reason not mentioned why you should not follow a regular exercise program? Yes No
If yes, please explain:
Have you recently experienced any chest pain associated with either exercise or stress? Yes No
If yes, please explain:
SMOKING
Please check the box that describes your current habits:
Non-user or former user; Date quit:_______________________
Cigar and/or pipe
15 or less cigarettes per day
16 to 25 cigarettes per day
26 to 35 cigarettes per day
More than 35 cigarettes per day
CARDIOVASCULAR
Please fill in the information below:
High Blood Pressure:_____________________ Hypertension:_____________________
High Cholesterol:__________________________________________________________________
Hyperlipidemia:____________________________________________________________________
Heart Disease:_____________________________________________________________________
Heart Disease:_____________________________________________________________________
Heart Attack:____________________________ Stroke:____________________________
Angina:_________________________________ Gout:_____________________________
HealthHistory_0805
International Sports Sciences Association
MUSCULOSKELETAL INFORMATION
Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back
pain, or general discomfort:
Head/Neck:_______________________________________________________________________________________________
Upper Back:______________________________________________________________________________________________
Shoulder/Clavicle:___________________________________________________________________________________________
Arm/Elbow:____________________________________________________________________________________________
Wrist/Hand:____________________________________________________________________________________________
Lower Back:___________________________________________________________________________________________
Hip/Pelvis:____________________________________________________________________________________________
Thigh/Knee:____________________________________________________________________________________________
Arthritis:______________________________________________________________________________________________
Hernia:______________________________________________________________________________________________
Surgeries:____________________________________________________________________________________________
Other:_______________________________________________________________________________________________
NUTRITIONAL INFORMATION
Are you on any specific food/diet plan at this time? Yes No
If yes, please list:
How many beverages do you consume per day that contain caffeine?
Other food/nutritional issues you want to include (food allergies, mealtimes, etc.)
HealthHistory_0805
International Sports Sciences Association
Please make any other comments you feel are pertinent to your exercise program.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Please note: possession of this form does not indicate certification status with the ISSA. To
confirm active certification status, please call 1.800.892.4772 (1.805.745.8111 international).
Information gathered from this form is not shared with ISSA. ISSA is not responsible or
liable for the use or incorporation of the information contained in or collected from this
form. Always consult your doctor concerning your health, diet, and physical activity.
NAME: ________________________________________________________________________________
HealthHistory_0805
International Sports Sciences Association
r This patient may not participate. (If checked, the individual will not be accepted.)
r Other:
Diagnosis/Recommendations/Comments:
SIGNATURE
Please note: possession of this form
does not indicate certification status
with the ISSA. To confirm active
PHYSICIAN NAME (please print) certification status, please call
1.800.892.4772 (1.805.745.8111
international). Information gathered
from this form is not shared with
PHYSICIAN SIGNATURE DATE ISSA. ISSA is not responsible or
liable for the use or incorporation of
the information contained in or col-
PARTICIPANT NAME (please print) lected from this form. Always con-
sult your doctor concerning your
health, diet, and physical activity.
Contents
Letter Writing
Writing Referral Cards
Letter Writing
LETTERS OF INTRODUCTION
A professional letter written to a prospect may be one of the single most important marketing strategies you can
develop. Even if prospects don't read flyers, or answer all of their phone messages immediately, most people read
their mail every day. That letter may convince them to make that call that they have thought about, but have not
acted on yet.
Dear (Name),
In response to your recent inquiry about personal training, I would like to tell you a bit about my professional
qualifications.
Im certified by The International Sports Sciences Association as a Certified Fitness Trainer. This certification
is the most prestigious in the industry and it qualifies me to work with virtually any individual wishing to
improve their fitness.
Ive been a trainer since (Year) and have worked with more than (number) clients in my career. I have abun-
dant in-depth experience with virtually every form of exercise but most of my clients say that my greatest asset
is my ability to motivate and inspire people.
I invite you to call me at (phone number) any morning between 9 A.M. and 10 A.M. so we can discuss your fit-
ness objectives and see if I may be of service to you.
Sincerely,
John Q. Trainer
IntroLetter_0805
International Sports Sciences Association
Many doctors and allied health practitioners like to do business (i.e.: patient referrals) through referral cards.
These are printed pieces that give brief descriptions of the services that are going to take place. If these profes-
sionals are familiar with your work, and are willing to refer, then this card may be ideal for them to give to patients
who may wish to work with you when they have completed their initial health care.
Name of Patient:________________________________________________________________________
Diagnosis: _____________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________
Type of Service(s):
Specific Recommendations:
ReferralCard_0805