JAMESIVES FITNESS

Health and Fitness Assessment

_________________________________________________________________

Personal Details:

Gender:
Address: __________________________
Male Female
Suburb: ____________________
Name: ___________________ Postcode: ________
Surname: ________________
Phone: ____________________
Date of Birth: _____________ Mobile: ____________________
Email: ______________________________
Emergency Contact Name: _________________________
Emergency Contact Phone: ____________________
Occupation: ____________________

Health and Fitness Goals

Number one goal: _______________________________________

Achieve this by: _________________________________________
Why is the goal important? ________________________________
Are there any barriers/reasons that would prevent you from
achieving these goals?
_______________________________________________________
Are you currently exercising or playing sport? ________________
The type, duration, intensity & how many times per week of the
particular exercise/sport:
_______________________________________________________
_______________________________________________________
Have you previously exercised or played any sport in the past?
Please describe:
_______________________________________________________
_______________________________________________________
Are you on an eating plan/diet? Please describe your eating
patterns and what you would consume on a regular day:
_______________________________________________________
_______________________________________________________
_______________________________________________________
Would you like guidance with your current eating patterns?
________________
From 1 to 10, how motivated are you to change your lifestyle and
what motivates you to do so?
Lacking motivation

1 2 3 4 5 6 7 8 9 10 Highly motivated

_______________________________________________________
_______________________________________________________

Please choose the number below to describe how youre

currently feeling now:
How energetic do you feel?
I just want to sleep 1
2
3
4
5 I am the energizer bunny
How healthy do you feel?
I am always sick 1
2
3
4
5 Whats a doctor?
How fit do you feel?
I get puffed looking at stairs 1
2
3
4
5 I can run the
stairs while talking

How strong do you feel?

I need help to carry groceries 1
2
3
4

I can easily lift

my own body weight

Lifestyle Review
What time of the day would you be most dedicated to your
exercise program?
Morning
Day
Afternoon
Evening
Preferred no of sessions / week: __________________
Preferred session duration: ______________________
Please choose which types of exercise/activities that interest you:
Walking Running Swimming Stationary Cycling
Rower Stepper Cross Trainer Free Weights
Sport: _______________________
Group Exercise Classes: ______________________
Other: _______________________
Health Check To be completed with trainer
Resting HR: ______ bpm
Low Normal High
Resting BP: ______ mm Hg
Norm Prehyp Hyp
Waist Girth: ______ cm
Hip Girth: ______ cm
W:H Ratio: ______ cm Low Moderate High Very high

Agreement for participating in exercise

I acknowledge that it is of participating in exercise that I do so
at my own risk
I accept all risks and herby indemnify and release the
instructor, their agents, affiliates, employees, members,
sponsors, promoters and any person or body directly and
indirectly associated with the Trainer, against all liability
(including liability for their negligence and the negligence of
others) claims, demands, and proceeding arising out of or
connected with my participation in this exercise
I acknowledge that participating in exercise may involve a risk
of serious injury or even death from various causes including:
over exertion, dehydration, equipment, failure and accidents
with equipment and surroundings
I recognise the difficulties associated with the activity and
attest I am physically fit to participate safely in the activity
and that a qualified medical practitioner has not advise me
otherwise
I understand the demanding physical nature of exercise. I am
not aware of any medical conditions, injury or impairment
that will be detrimental to my health if I participate in
exercise. In the event, I become aware of any medical
condition, injury or impairment that may be detrimental to
my health, the instructor will be immediately informed. By
continuing to participate in this exercise, I accept the risks
despite these conditions and am still, and will always be
under the terms of this agreement
I certify that I am 18 years or older and have read this
document and fully understand it OR as a parent or guardian
of the participant (a) I agree to the above for myself and on
behalf of the participant and (b) I indemnify and will keep
indemnified any person or body directly or indirectly
Associated with the conduct of the exercise on these terms.

Signature: (guardian/parent to sign if under 18 years of age)

Full name (Please print):

Date:

__________________________

___________________________

Trainers Name:

Trainers Signature:

__________________________

___________________________

Feedback and Confirmation

How did you hear about JAMESIVES FITNESS?
_______________________________________________________
What do you consider important for a personal trainer to
possess?
_______________________________________________________
Did you know that JAMESIVES FITNESS is a Mobil PT service?
Are you willing to travel to different suburbs in the west for Boot
Camp?
_______________________________________________________
Are there any exercises that you dislike?
_______________________________________________________

ADULT PRE-EXERCISE SCREENING TOOL

This screening tool does not provide advice on a particular matter,
nor does it substitute for advice from an appropriately qualified
medical professional. No warranty of safety should result from its
use. The screening system in no way guarantees against injury or
death. No responsibility or liability whatsoever can be accepted by
Exercise and Sports Science Australia, Fitness Australia or Sports
Medicine Australia for any loss, damage or injury that may arise
from any person acting on any statement or information contained
in this tool.
Name: __________________________________________________
Date of Birth: _______________________

Male

Female

Date: ____________________

STAGE 1 (COMPULSORY)
AIM: To identify those individuals with a known disease, or signs or
symptoms of disease, who may be at a higher risk of an adverse
event during physical activity/exercise. This stage is self-administered
and self-evaluated.

1. Has your doctor

ever told you that
you have a heart
condition or have
you ever suffered a
stroke?

2. Do you ever
experience
unexplained pains in
your chest at rest or
during physical
activity/exercise?

3. Do you ever feel

faint or have spells of
dizziness during
physical
activity/exercise that
causes you to lose
balance?

4. Have you had an

asthma attack
requiring immediate
medical attention at
any time over the
last 12 months?

Yes

No

Yes

No

Yes

No

Yes

No

5. If you have
diabetes (type I or
type II) have you had
trouble controlling
your blood glucose in
the last 3 months?

6. Do you have any

diagnosed muscle,
bone or joint
problems that you
have been told could
be made worse by
participating in
physical
activity/exercise?

7. Do you have any

other medical
condition(s) that may
make it dangerous
for you to participate
in physical
activity/exercise?

Yes

No

Yes

No

Yes

No

 IF YOU ANSWERED YES to any of the 7 questions, please seek

guidance from your GP or appropriate allied health

professional prior to undertaking physical activity/exercise
IF YOU ANSWERED NO to all the 7 questions, and you have

no other concerns about your health, you may proceed to

undertake light-moderate intensity physical activity/exercise

I believe that to the best of my knowledge, all the information

I have supplied within this tool is correct.
Signature: ______________________

Date: ____________