Personal Training Client Information Packet

Personal Training
Client Information Packet
Welcome to Cleveland State University’s Campus Recreation Center!
Thank you for your interest in our Personal Training program. We want to help you
reach your health and fitness goals by pairing you up with one of our qualified trainers.
Before you begin your program, please take a moment to fill out the following
information.
This packet includes the following:
•
Personal Training Client Information Form
•
ACSM Health Status and Health History Questionnaire
•
Informed Consent Form for Fitness Assessments
•
Personal Training Prices and Information
All information submitted in this packet will be kept confidential. Client information regarding health
history in any form may only be accessed by appropriate staff of Cleveland State University Campus
Recreation. Appropriate staff may include, but is not limited to, your current personal trainer, the Fitness
and Wellness Coordinator, and the Associate Director of Programs. Please review the Member Policies
and Procedures Manual for all inquiries concerning the Personal Training program.
Should you have any further questions, please contact Justin Porter, Graduate
Supervisor of Fitness and Wellness, at 216.802.3210 or j.a.porter65@csuohio.edu.
Nutritional Preparation
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Ensure you are well nourished on the day of training.
Where possible, consume a high carbohydrate diet in the 24 hours prior to the training
sessions (such as pasta, potatoes, cereals, toast, fruit etc.).
You are strongly advised to have eaten some food in the four hours preceding training.
Ensure you are fully hydrated, particularly in hot conditions. Drink regularly in the days
leading up to the training, particularly in the 12 hours prior to training.
Top up body fluids by drinking water regularly throughout the training session. Continue
to consume adequate fluids following exercise to replace any fluids lost during training.
What to wear/bring
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Wear appropriate clothing for the conditions (e.g. shorts/track pants and
t-shirt/singlet/sports top) and non-slip athletic footwear with laces securely fastened.
No jeans, or non-secure shoes (i.e. sandals)
Remove restrictive jewelry, watches, bracelets or hanging earrings that may get caught in
equipment.
Bring a bottle of water, and sweat towel if needed
Personal Training will give you:
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Personal trainers that are certified with a
national organization
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Private, hour-long session
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A customized exercise program based
on your personal fitness goals and
specific needs
Other services included with your
session:
Body Composition
This 30-minute appointment gives you feedback
on your genetic makeup with a 7-site caliper test
that measures both lean and fat tissue. A brief
consultation about your results can help you set
up your fitness goals and wellness plans.
Fitness Assessments with MicroFit®
This 60-minute appointment tests your muscular
strength and endurance, flexibility, cardiovascular fitness, and body composition. It can provide
you with a baseline fitness level as well as help
you plan out your perfect training regimen. Now
with our
MicroFit® software, you can expect
accurate results to help you plan the perfect routine for your fitness goals!
Questions? Concerns? Contact Graduate Supervisor,
Fitness & Wellness, Justin Porter
216.802.3210 or j.a.porter65@csuohio.edu
Levels of Personal Trainers
Level 1 Trainers
Level 1 trainers are skilled professionals with the knowledge and resources to assist clients with various goals
and interests. These goals range from weight loss to
sport-specific training. Many of these professionals have
acquired a national certification or four-year degree, while
some are Cleveland State students who are earning
health-related, exercise science and/ or physical therapy
degrees. You can expect Level 1 Trainers to provide
safe, effective, and challenging workouts that incorporate
goal setting and education into your personal plan.
Level 2 Trainers
Level 2 trainers have an advanced level of experience,
education, and training, and are experienced problem
solvers with several years of experience. They have the
expertise to assist clients in addressing chronic
diseases*, injury rehabilitation, pre- and post-natal
training, advanced sport conditioning, and training for
older adults. You can expect Level 2 Trainers to provide
more advanced coaching and instruction for you.
*Note: Level 2 trainers cannot diagnose or treat any
medical condition.
Level 1
Level 2
Member
Non-Member
Member
Non-Member
1 session
$30
$45
$30
$45
MicroFit® Body
Composition
30 Minute Session
$10
$15
$10
$15
Individual Training
Member
Non-Member
Member
Non-Member
1 session
5 sessions
10 sessions
$30
$145
$280
$45
$220
$430
$45
$220
$430
$60
$295
$550
20 sessions
$540
$840
$840
$1,000
Member
Non-Member
MicroFit® Fitness
Assessment
Pair Training
Member (both Non-Member ( Or
need to be
Mixed of Mem&
members)
NonMem rate)
1 Session
$50
$70
$70
$100
5 Sessions
$220
$330
$330
$440
Contact the Recreation Center at 216-802-3201 for help selecting a
trainer based on your needs and goals. For additional information or
to purchase training sessions, stop by the CSU Recreation Center
Pro Shop.
Personal training sessions are available by appointment only. You
must come to the Recreation Center and fill out a Personal Training
Packet as well as purchase a training session to get started today!
PERSONAL TRAINING CLIENT INFORMATION FORM
CLEVELAND STATE UNIVERSITY CAMPUS RECREATION
Please answer each of these questions as accurately as you can. Should you have any questions, feel free
to ask. Your responses will be treated in a confidential manner.
Today's Date:
/
/
Your Name:
Member/Student ID:
Membership Status: Student
/
Date of Birth:
Faculty/Staff
Alumni
Community
Non-Member
/
Address:
City:
State:
Zip:
Home Phone: ______________________________________________________________
Day Ph:
Email Address:
Preferred Method of Contact: E-mail
or
Phone
or
Text
Phone:
Emergency Contact:
Your Availability*:
Mobile:
(Days of the week, time of day)
__________________________________________
_______________________________________________________________
Trainer Preference:
Female
Male
No Preference
OR
Trainer Request:
_______________________________________________________________
Level I or Level II
* Please note that limited client availability may result in a longer wait before being matched with a trainer.
Informed Consent for Personal Training and Programs
Fitness Assessment Testing
The purpose of any fitness assessment is to provide a framework for developing appropriate
exercise prescription for a variety of populations. By participating in this program, you are
assisting the trainer assigned to you to gain practical experience in developing exercise
prescriptions, identifying risk factors, physiological responses to exercise, affects of medications
on exercise, tolerance of exercise, exercise selection, and testing protocol for various
populations.
The purpose of fitness testing is to evaluate a client’s baseline fitness level and develop an
exercise program based on client’s specific goals. The assessment consists of quiet testing:
Heart Rate, Blood Pressure, Height, and Weight. Anthropometric measures consist of BMI,
waist to hip ratio, and body composition using skinfold caliper. We will then proceed into the
cardio-respiratory, muscular strength and endurance, and, lastly, flexibility portions of the
testing.
I understand that I am responsible for meeting with my trainer on assigned dates and times. I
also understand that I am responsible for monitoring my own condition throughout the
assessment, and should any unusual symptoms occur, I will cease my participation and inform
the person administering the assessment and my assigned trainer immediately of the
symptoms.
In signing this consent form, I confirm that I have read this form in its entirety and that I
understand the description of the assessment and the components. I also have had my
questions regarding the assessment answered to my satisfaction.
Also, in consideration for participating in the assessment, I agree to assume the risk of such
testing, and further agree to hold harmless Cleveland State University, Campus Recreation
Services, and the trainer conducting such testing from any and all claims, suits, losses, or
related causes of action for damages, including, but not limited to, such claims that may result
from injury or death, accidental or otherwise, during, or arising in away from, the program.
_________________________________________
Signature of participant
_________________________
Date
_________________________________________
Person administering assessment
_________________________
Date
Campus Recreation Services
Mailing Address: 2420 Chester Ave Recreation Center  Cleveland, Ohio 44115-2214
Phone: (216) 802-3200  www.csuohio.edu/recreation_center
ACSM HEALTH STATUS & HEALTH HISTORY QUESTIONNAIRE
CLEVELAND STATE UNIVERSITY CAMPUS RECREATION
This form includes several questions regarding your physical health – please answer every question as accurately as
possible. Please ask us if you have any questions. Your responses will be treated in a confidential manner.
PERSONAL INFORMATION
Last Name: _________________________________ First Name: ____________________________ Gender: F M
Ethnicity:
(check all that apply)
□ American Indian/Alaska native
□ Caucasian/European
Date of Birth _____/_____/_______
YES NO
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□
□
□
□
□
□
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□
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□ Asian
□ Hispanic/Latino
Height __________
□ Black or African-American
□ Native Hawaiian/Pacific Islander
Weight __________
(ACSM HEALTH SCREEN)
□ Do you have any personal history of heart disease (coronary or atherosclerotic disease)?
□ Any personal history of diabetes or other metabolic disease (thyroid,renal,liver)?
□ Any personal history of pulmonary disease, asthma, interstitial lung disease or cystic fibrosis?
□ Have you experienced pain or discomfort in your chest apparently due to blood flow deficiency?
□ Any unaccustomed shortness of breath (perhaps during light exercise)?
□ Have you had any problems with dizziness or fainting?
□ Do you have difficulty breathing while standing or sudden breathing problems at night?
□ Have you experienced a rapid throbbing or fluttering of the heart?
□ Do you suffer from ankle edema (swelling of the ankles)?
□ Have you experienced severe pain in leg muscles during walking?
□ Do you have a known heart murmur?
□ Has your serum cholesterol been measured at greater than 200 mg/dl?
□ Are you a cigarette smoker?
□ Has your HDL (the "good" cholesterol) been measured at greater than 60 mg/dl?
□ Would you characterise your lifestyle as "sedentary"?
□ Have you had a high fasting blood glucose level on 2 or more occasions (>=110mg/dl)?
□ Are you 20% or more overweight or have you been told your “BMI” was greater than 30?
□ Have you been assessed as hypertensive on at least 2 occasions (systolic > 140mmHg or diastolic > 90mmHg)?
□ Do you have any family history of cardiac or pulmonary disease prior to age 55?
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MEDICAL HISTORY
□ Are you currently being treated for high blood pressure?
If you know your average blood pressure, please enter:
/
Please check all conditions or diagnoses that apply:
□ Abnormal EKG?
□ Abnormal Chest X-Ray?
□ Rheumatic Fever?
□ Low Blood Pressure?
□ Asthma?
□ Bronchitis?
□ Emphysema?
□ Other Lung Problems?
□ Limited Range of Motion?
□ Arthritis?
□ Stroke?
□ Do You Suffer from
Epilepsy or Seizures?
□ Bursitis?
□ Chronic Headaches or
□ Swollen or Painful Joints?
□ Foot Problems?
□ Knee Problems?
□ Back Problems?
□ Shoulder Problems?
□ Recently Broken Bones?
□ Has a doctor imposed any activity restrictions? If so, please describe:
FAMILY HISTORY
Have your mother, father, or siblings suffered from (please select all that apply):
□ Heart attack or surgery prior to age 55.
□ High cholesterol
□ Stroke prior to age 50.
□ Diabetes
□ Congenital heart disease or left ventricular
□ Obesity
hypertrophy.
□ Hypertension
□ Asthma
□ Leukemia or cancer prior to age 60.
□ Osteoporosis
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Migraines?
□ Persistent Fatigue?
□ Stomach Problems?
□ Hernia?
□ Anemia?
□ Are You Pregnant?
MEDICATIONS
Please Select Any Medications You Are Currently Using:
□ Diuretics
□ Other Cardiovascular
□ Beta Blockers
□ NSAIDS/Anti-inflammatories (Motrin, Advil)
□ Vasodilators
□ Cholesterol
□ Alpha Blockers
□ Diabetes/Insulin
□ Calcium Channel Blockers
□ Other Drugs (record below).
Please list the specific medications that you currently take:
LIFESTYLE
□ Are you a cigarette smoker?
If so, how many per day?
□ Previously a cigarette smoker?
If so, when did you quit?
How many years have you smoked or did you smoke before quitting?
Do you/did you smoke (Circle one): Cigarettes
Cigars
Pipe
Please Rate Your Daily Stress Levels (select one):
□ Low
□ Moderate □ High but I enjoy the □ High: sometimes
challenge
difficult to handle
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□ High: often difficult to
handle.
Alcohol Units Table
□ Do you drink alcoholic beverages?
Type of Drink
Units
How many units of alcohol do you
½ pint of beer
1
consume per week: ______
1 glass of wine
1
(see Alcohol Units Chart)
1 pub measure of spirits (Gin, Vodka
etc.)
1
1 can of beer
1.5
1 bottle of strong lager
2.5
1 can of strong lager
4
1 bottle of wine
7
1 litre bottle of wine
10
1 bottle of fortified wine (port, sherry
etc.)
14
1 bottle of spirits
30
Dietary Habits. Please Select All That Apply.
□ I seldom consume red or high-fat meats.
□ I eat at least 5 servings of fruits/vegetables per day.
□ I pursue a low-fat diet.
□ I almost always eat a full, healthy breakfast.
□ My diet includes many high-fiber foods.
□ I rarely eat high-sugar or high-fat desserts.
OTHER HEALTH HISTORY INFORMATION
Please indicate any other medical conditions or activity restrictions that you may have, or any other information you feel
is critical to understanding your readiness for exercise. It is important that this information be as accurate and complete as
possible
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HEALTH AND FITNESS GOALS
Pleasee indicate your personal health and fitness-related goals (select all that apply):
□ Cardiovascular Fitness
□ Feel Better
□ General Fitness
□ Improve Diet
□ Improve Flexibility
□ Injury Rehab
□ Look Better
□ Lose Weight
□ Lower Cholesterol/Blood Pressure
□ Muscular Size
□ Muscular Strength
□ Reduce Stress
□ Reduce Back Pain
□ Sport-Specific Training
□ Stop Smoking
Pleasee tell us a little about your exercise patterns and goals:
What is your exercise history?
What health improvements do you need?
What are your activity preferences?
What barriers to success do you anticipate?
How will you know that you are succeeding?
What is your motivation level?
□ High
□ Medium
What is your confidence level?
□ Low
□ High
□ Medium
□ Low
I verify that all of the completed information is correct to the best of my knowledge. I understand that I may need to
consult my physcian before starting any exercise program and I will make any necessary arrangements to obtain a medical
clearance to exercise should I be asked.
______________________________
Printed Name
______________________________
Signature
Page 5 of 5
____________________
Date