Sports Performance Client Questionnaire

Sports Performance Client Form

Athlete Information

Athlete's Name(Required)

First Last

Athlete's Address(Required)

Street Address Address Line 2 City State ZIP Code

Athlete's Cell Number(Required)

Athlete's Gender

Athlete's current grade (if applicable)

Athlete's Primary Sport and Position if applicable

Athlete's Secondary Sport(s) if applicable

Athlete's Date of Birth(Required)

Athlete's Email Address(Required)

Parent or Guardian Name if Athlete is under 18 years old

First Last

Parent/Guardian Email Address(Required)

Parent or Guardian Address if different from Athlete's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Name(Required)

First Last

Emergency Contact Relationship(Required)

Emergency Contact Phone(Required)

Par-Q and Medical History

Physical Activity Readiness Questionnaire

1. Has a doctor ever said you have a heart condition and that you should only perform physical activity recommended by a doctor?

Yes

2. Do you feel pain in your chest when performing physical activity?

Yes

3. In the past month, have you had chest pain when NOT performing physical activity?

Yes

4. Do you lose balance because of dizziness or do you ever lose consciousness?

Yes

5. Do you have a bone or joint problem that could be made worse by a change in your/his/her physical activity?

Yes

6. Is your doctor currently prescribing any medication for blood pressure or a heart condition?

Yes

7. Do you know of any reason why you should not engage in physical activity?

Yes

8. Has a medical doctor ever diagnosed you with a chronic disease? If yes, please explain.

9. Please tell me about any pain or injuries you have experienced or currently experience in the ankle, knee, hip, back, elbow, shoulder or neck. Please indicate if any of these are sports related. If none, please state so.

10. Please tell me about any surgeries you have had. If none, please state so.

Training Goals and History

This is the fun stuff!

1. What results would you like to see from your training for the short term (this or next season)?

2. What results would you like to see from your training for the long term?

3. What skill needs the most development to get you to your goal?

4. What is your best skill/strength as an athlete?

5. On a scale of 1-10, how determined are you?

6. What are the key reasons you decided to work with a sports performance coach?

7. Currently, what are your training, recovery, and injury prevention habits (lifting, cardio, nutrition, sleep, mobility and flexibility work)?

8. Finally, I strongly encourage communication between you and me. Let me know if you are having trouble maintaining your workout schedule, if you are feeling overly fatigued, or if you are not that excited about your workouts. I also encourage you to let your family know how important your goals and training are to you so they can have the opportnity to support you in this endeavor. Looking at your work or schoolwork, family and other responsibilities/activities, how much time and how many days of training (including recovery work) do you feel is realistic each week?

Waiver

I understand that I am purchasing training sessions for myself and must read, agree to and sign this agreement where I assume the risks for participation, waive of liability, and agree to the Total Strength Fitness policies and procedures.

I understand that the program is voluntary and that a Certified Personal Trainer/Weightlifting Performance Coach/Sports Performance Coach/Running Coach will lead the training which includes high intensity exercises including weight lifting, plyometrics, and/or running. I represent that I will complete the PAR-Q and any other health history form accurately and completely including disclosure of any exercise limitations I am aware of or have been informed of by my doctor. During the program if my condition or medical limitations should change, I will notify the Trainer. I understand that it is recommended that I have a yearly physical or more frequent physical examination and consultation with my physician as to physical activity and diet so I am aware of what is appropriate for me. I acknowledge that I have had a physical exam and have been given a physician’s permission to participate, or I have decided to allow myself to participate without approval of a physician.

I understand that a Trainer will review my PAR-Q and any other health history form but that a Trainer is not a physician and cannot replace the advice and expertise of a qualified physician.

I understand that I have the complete right to stop or decrease my exercise at any time during a session and that it is my obligation to inform the Trainer of any symptoms such as fatigue, shortness of breath or chest discomfort.

I realize that participation in an exercise training program includes but is not limited to exercising, use of exercise equipment and strenuous exertion (such as strength training or high intensity aerobic activity) which will increase heart rate and body temperature.

I understand that exercise involves certain risks, including but not limited to, serious neck and spinal injuries resulting in complete or partial paralysis, heart attack, stroke or even death. Also, injuries could occur to bones, joints or muscles. Slips, falls, and unintended loss of balance could result in muscular, neurological, orthopedic or other bodily injury. I understand that part of the risk involved in undertaking any activity or program is relative to my own state of fitness or health (physical, mental, or emotional) and to the awareness, care and skill which I conduct myself in that activity or program. I understand that proper form of any exercise (as described and/or demonstrated by Trainer) performed by me is a necessary and essential component of an exercise program.

Knowing the material risks and knowing and reasonably anticipating that other injuries are a possibility, I hereby expressly assume all of the delineated risks of injury, all other possible risk of injury, and even risk of possible death, which could occur by reason of my participation.

I do hereby waive, release and forever discharge Total Strength Fitness and the Back on Track program from any and all responsibilities or liability for any present and future injuries or damages resulting or arising from my participation in any activities including but not limited to exercise, group training, track meets, or use of the equipment used within the Back on Track program.

I AGREE AND UNDERSTAND.(Required)

Initial Here. (Parent/Guardian if athlete is under 18)

Billing Information

Client can choose to pay for training sessions at the time of the session, or invoices are sent the day of the session via PayPal. Client does not need a PayPal account to pay the invoice. Invoices can be paid by any card, PayPal, Venmo or check.

Signature (Parent/Guardian if athlete is under 18)(Required)

Please provide signature via touchscreen, touchpad or mouse.

Name

This field is for validation purposes and should be left unchanged.