Client Initial Assessment Worksheet: How Did You Here About Us or Who Referred You?

Client Initial Assessment Worksheet
Name: ____________________________________ Date: ___________

Address: _______________________ City___________________ ST____ ZIP________
Contact Numbers: (HM) ____________________ and (Cell) ______________________
Email: ____________________________________
Gender:  Male  Female Date of Birth: __________ Height: _____
Emergency Contact:
Name: _______________________________ Number: ___________________________
(If female – Are you lactating or pregnant? Yes or  No)
How did you here about us or who referred you? _____________________________
Which of the following statements best describe you (check one):

 I can eat practically anything I want and I do not gain weight. I find it very hard to
gain weight.
 I can lose or gain weight by adjusting my activity level and eating habits.
 I find it difficult to lose weight. I can gain weight easily and should watch what I eat.
Please rate the activity level of your profession or what you during the day (excluding exercise):
 Sedentary  Moderately Active  Active  Very Active
What are your weight goals (circle one):

 Weight Loss What is your goal weight? _____________
 Maintaining/Improve Eating Habits
 Weight Gain
To Be Completed By Your Personal Trainer
Physical Assessment Data: Fitness Assessment Data:
A. Body Weight (lbs.): ___________ A. Cardio Endurance: 3 Min. Step Test (bpm) ________
B. Body Fat %: ___________ B. Upper Body Strength: Push Ups (#) _________
 Normal  Athlete
C. Abdominal Strength: 1 Min. Sit ups (#) _________
C. Chest: ___________ D. Waist: ___________
D. Lower Body Strength: Squat Test (#) _________
E. Hips: ___________
E. Flexibility Sit & Reach (inches) __________
F. Arms: L__________R__________
ame: __________________
G. Thighs: L__________ R__________
MEDICAL HISTORY
1. When was your last physical examination? ___________________________
2. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? Y / N

________________________________________________________________
3. Do you have a seizure disorder (epilepsy)? Y / N

________________________________________________________________
4. Do you take any prescribed medication on a permanent or semi-permanent

basis? Y / N If Yes, List Any Medications:
________________________________________________________________
________________________________________________________________
5. Do you have diabetes Adult or Juvenile? Y / N
6. Have you ever been found to be anemic (low blood count)? Y / N
7. Do you have High Blood Pressure (hypertension)? Y / N
8. Do you currently have high cholesterol? Y or N What is it? __________
9. Any cardiovascular problems (abnormal heartbeat, heart attacks etc.) Y or N

Explain: ______________________________________
10. Do you smoke? Y / N If Yes, how many per day? __________
11. Do you drink beer/alcohol? Y/ N If Yes, How many per week? _________
12. Have you been under the guidance/advice of a psychologist? Explain.

________________________________________________________________
________________________________________________________________
13. Have you had any surgeries pertaining to gastro bypass or lap band? If so,
please list dates of surgery. ____________________________________
14. Do you have any medical conditions or problems than cause pain not
previously mentioned? If yes, explain.
_________________________________________________________
________________________________________________________________
LIABILITY & RELEASE FORM
This release is entered between me _______________________ and DandM FITNESS GT.
The purpose of DandM FITNESS GT is to provide fitness and exercise instruction.
I hereby acknowledge that the following was explained to me and/or agree to the following:
1. Acknowledges that DandM FITNESS GT is not a physician and is not trained in any way to
provide medical diagnosis, medical treatment, psychotherapy, or any other type of medical
advice.
2. Acknowledges that fitness training is another tool for teaching individuals about themselves,
but that DandM FITNESS GT does not guarantee neither good nor bad will occur nor
guarantees the coaching advice given by DandM FITNESS GT will produce neither good nor
bad results.
3. Acknowledges that DandM FITNESS GT may suggest exercise as part of my fitness

program/lifestyle management. I further understand that by participating in boot camps, ZUMBA
fitness, swimming, cycling (on and off road), in-line skating, triathlon, x-c skiing, weight training,
aerobic classes, martial arts, kick boxing, kung-fu, and any other related sports are an extreme test
of one's mental and physical limits and carry with it potential for damage or loss of property,
serious injury and death. That I, assume all risks of participating in these types of events and/or
activities, that I am fit, and that I have a regular medical physician that I can contact regarding
any medical problems that I might develop. By signing this document, I expressly waive, release,
discharge and agree not to sue from any liability of death, disability, personal injury, or action of
any kind the DandM FITNESS GT facility, instructors, or any person involved in this program
or testing procedures for me participating in said sporting events and/or training for said
sporting/fitness activities.
4. I agree that this is the full agreement between DandM FITNESS GT and myself and that
DandM FITNESS GT, nor anyone else has not verbally contradicted any of the terms of this
release and that I have entered this agreement free and voluntarily without force or coercion.
PUBLICITY RELEASE: I grant DandM FITNESS GT the right to photograph and/or videotape me
and/or my child/ward and to use my and/or my child’s/ward’s name, face, likeness, voice and appearance in
connection with exhibitions, publicity, advertising, and promotional materials for the Activities without
reservation or limitation.
______________________________ _______________________________________
Name (Print) Email
______________________________ _______________________
Signature Date
Medical Clearance & Physician’s

Consent Form
To: DandM FITNESS GT

Arlington, TX 76001
dm@dandmfitness.com
Dear Certified Personal Trainer:
My patient, ________________________, has advised me that he or she intends

to participate in a fitness assessment. This assessment will include muscular
endurance and flexibility tests, body composition assessment, a blood pressure
reading, and cardiovascular fitness assessment. An exercise program will be
designed based on this assessment which will include, but not be limited to,
resistance training and cardiovascular training. The sessions will last
approximately one hour, and will begin at a very moderate, sub-maximal level.
Please be advised that the above-mentioned patient should be subject to the

following restrictions in the fitness assessment and/or in his or her exercise
program:
In addition, under no circumstances should he or she do the following:
I have discussed the foregoing restrictions and limitations with my patient and,
with these specific restrictions, he or she has my permission to participate in a
fitness assessment and pursue an exercise program under your guidance.
Truly yours,
________________________ Date: _________________________

(Doctor Signature)
________________________ Phone number: _________________

(Doctor Printed Name)

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Client Initial Assessment Worksheet

Name: ____________________________________ Date: ___________

Gender:  Male  Female Date of Birth: __________ Height: _____

(If female – Are you lactating or pregnant? Yes or  No)

How did you here about us or who referred you? _____________________________

Which of the following statements best describe you (check one):

What are your weight goals (circle one):

Physical Assessment Data: Fitness Assessment Data:

1. When was your last physical examination? ___________________________

2. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? Y / N

3. Do you have a seizure disorder (epilepsy)? Y / N

4. Do you take any prescribed medication on a permanent or semi-permanent

5. Do you have diabetes Adult or Juvenile? Y / N

6. Have you ever been found to be anemic (low blood count)? Y / N

7. Do you have High Blood Pressure (hypertension)? Y / N

8. Do you currently have high cholesterol? Y or N What is it? __________

9. Any cardiovascular problems (abnormal heartbeat, heart attacks etc.) Y or N

10. Do you smoke? Y / N If Yes, how many per day? __________

12. Have you been under the guidance/advice of a psychologist? Explain.

This release is entered between me _______________________ and DandM FITNESS GT.

The purpose of DandM FITNESS GT is to provide fitness and exercise instruction.

3. Acknowledges that DandM FITNESS GT may suggest exercise as part of my fitness

Medical Clearance & Physician’s

To: DandM FITNESS GT

Dear Certified Personal Trainer:

My patient, ________________________, has advised me that he or she intends

Please be advised that the above-mentioned patient should be subject to the

In addition, under no circumstances should he or she do the following:

________________________ Date: _________________________

________________________ Phone number: _________________

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