New Client Intake Packet
INFORMED CONSENT (Please read in its entirety and sign below)

    I give my consent to participate in the physical adaptive fitness evaluation program or classes conducted by DPI Adaptive Fitness.

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, endurance, improved mobility, function, mood and decreased overall stress.

RISKS

I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and the cardiorespiratory 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.

TESTING AND EVALUATION RESULTS

I understand that I will undergo initial testing to determine my current physical fitness status (1:1 assessment). The use of Pictures may be implemented as baseline and ongoing measurements; I agree to release the use of pictures for educational & promotional purpose to (DPI). The testing will consist of completing this health inventory, functional movement screens and being tested for muscular fitness and body composition.
I further understand that such screening is intended to provide (DPI) with essential information used in the development of individual adaptive fitness programs.
 
I understand that my individual results will be made available only to me. I also understand that the testing is not intended to replace any other medical test or the services of my physician.

I will be provided a copy of all test results in a summary of my initial visit within 24-48 hours of completion. I may share the results with whomever I please, including my personal physician.

By signing this consent form I understand that I am personally responsible for my actions during my tenure at (DPI) whether in a group format or individual session and that I waive the responsibility of this group (DPI) if I should incur any injury as a result of my own negligence.
Email *
Participants Printed Full Name & Date *
Participant Electronic signature-Print full name to accept informed consent *
Participants diagnosis *
Participants Age & Date of Birth *
Participants Address & phone number *
Emergency Contact Name & Relationship *
Emergency Contact Phone Number *
If participant under 18, Guardian full printed name
Confidentiality Agreement
I understand that the information collected by DPI Adaptive Fitness will be used for adaptive fitness evaluation purposes and for the design, implementation, progression, and maintenance of an individualized adaptive fitness program only.

I further understand that all such information is confidential and will not be shared with anyone without my prior written authorization, except in the case of a medical emergency or to the minimum extent necessary to achieve a safe and effective adaptive fitness program.  
Participant Electronic signature-Print full name to accept confidentiality agreement *
Physical Activity and Readiness Questionare: Par Q
For your safety....In place of the Par Q a form for individuals aged 15-69, DPI Adaptive Fitness requires all individuals that participate in 1:1 adaptive fitness sessions to discuss and obtain a medical release before ANY ongoing sessions can be scheduled
Do you understand that you must obtain a medical release before ongoing 1:1 adaptive fitness sessions can begin that clear you for physical activity? *
MEDICAL SCREENING
Please check all that apply
Heart Attack *
Required
Bypass or cardiac surgery *
Required
Chest discomfort with exertion *
Required
High blood pressure *
Required
Rapid or runaway heartbeat *
Required
Skipped heartbeat *
Required
Rheumatic Fever *
Required
Phlebitis or embolism *
Required
Shortness of breath with or without exercise *
Required
Fainting or light headed *
Required
Pulmonary disease or disorder *
Required
High Cholesterol *
Required
Stroke *
Required
Recent hospitalization for any cause *
Required
Orthopedic problems-list all *
FOR ANY OF THE CONDITIONS CHECKED ABOVE, PLEASE LIST THE DIAGNOSIS AND EXAMINING PHYSICIAN:
Are you under the care of a physician, chiropractor or other health care professional? if yes, please list name and number of provider *
Are you currently under the care of a physical therapist? *
If you answered yes, please list your Physical Therapist name and organization
Do we have permission to contact your Therapist/Dr. regarding your adaptive fitness sessions? *
Are you taking any medications? if yes, please list (N/A if none) *
Please list any allergies you may have (N/A if none) *
Has your doctor ever said your blood pressure was too high? *
Required
Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise? *
Required
Are you unaccustomed to vigorous/Intense exercise programming? *
Required
Is there reason not mentioned why you should not follow a regular exercise program? if yes, please explain:
Have you recently experienced any chest pain associated with either exercise or stress? If yes, please explain:
PLEASE CHECK THE BOX THAT DESCRIBES YOUR CURRENT HABITS
Smoking *
Alcohol *
Caffeine *
Nutrition *
Current Activity Level *
What activities do you currently perform? *
Activity Level before injury or illness *
What activities did you participate in before your injury or illness *
Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort: *
What are your expectations from working with DPI Adaptive Fitness & Personal Training: (check all that apply)? *
Required
Please list any other goals you would like to address: *
How did you hear about us? *
Client/Trainer Agreement (Please Read Entire Agreement Before Signing)
1. Fees

Payment of fees for adaptive fitness sessions, memberships, or group classes will be due prior to the beginning of sessions or classes.

We accept all major credit cards. All credit card purchases are subject to a 3% convenience fee

We accept check payments and are set up to keep checking info on file for automatic transfers which is also subject to the 3% convenience fee.

In person Check & Cash payments are also acceptable and is not subject to the 3% convenience fee

2. Scheduling

Sessions are to be made by appointment only to reserve your time slot. Appointments can be made in person during a session with your trainer or on our website (schedule with a trainer page) 

Sign ups are required for ALL classes at dpi adaptive fitness, you can sign up on our class sign up page on the website at dpiadaptivefitness.com

3. Cancellations

Cancellations must be made at least within a 24-hour period to allow for the trainer to utilize the time slot accordingly. Abuse of our cancellation policy (2 no show or cancellations will incur a 1/2 session charge)

4. Photo use

We love to educate and highlight all of the hard work and goals achieved in our adaptive gym

It is not uncommon to see photos of classes or sessions on our social media or in our educational presentations to the community. Your participation in our programming may result in your likeness being used in such posts or presentations.

You understand that by signing this you are releasing use of any photos of yourself.

5. Hard work

We are a results driven, progress oriented adaptive fitness gym. We will push to achieve your goals while ensuring a safe adaptive environment, only utilizing safe effective programming individualized to your goals and needs. We ask that you come focused, determined and ready to work really hard for results and best outcomes
Participant Electronic signature-Print full name to accept client trainer agreement *
Baseline Testing: (DPI STAFF ONLY FROM HERE ON)
Body Measurement: (use form) Body Fat percentage: ____________
Weight: _______________
Push Up Test (1 Min only-List modifications and Rate of Perceived exertion) DPI TRAINER ONLY
Sit Up Test (1 Min only-List modifications and Rate of Perceived exertion) DPI Trainer Only
Squat/Sit to stand Test (1 Min only-List Modifications, height of surface, assistance device and Rate of Perceived exertion) DPI Trainer Only
Stork Test/Modified Stork Test (30 sec-List modifications for performance. Test Right & Left and Rate of Perceived exertion) DPI Trainer Only
Seated Trunk balance test (Sit & Reach) List Modifications and Rate of Perceived exertion DPI Trainer Only
 Transfer Testing (List type of transfer, level of assist and Rate of Perceived exertion) DPI Trainer Only
Get up & Go Test: (List Modifications, and Rate of Perceived exertion.Take best time of two trials) DPI Trainer Only

6MWT: Six Minute Walk Test (List Modifications, Assistive Device and Rate of Perceived exertion) DPI Trainer Only

Berg balance test (List Modifications as needed, and Rate of Perceived exertion, Berg Balance Testing on file) DPI Trainer Only
Back Scratch Test (List limitations to complete, any discomfort and Rate of Perceived exertion) DPI Trainer Only
4 stage balance Test (List Modification and Rate of Perceived exertion (DPI Staff Only)
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