New Client Intake Packet
INFORMED CONSENT

I, (print name) _______________________________________ , 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 purpose to (DPI). The testing will consist of completing this health inventory, taking a step test or bicycle ergometer test for cardiovascular fitness, 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. 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 address *
Participants diagnosis *
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Participants Printed Full Name & Date *
Your answer
Participants Age & Date of Birth *
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Participants Address & phone number
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Emergency Contact Name & Relationship *
Your answer
Emergency Contact Phone Number *
Your answer
If participant under 18, Guardian full printed name
Your answer
Participant Electronic signature-Print full name to accept *
Your answer
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 *
Your answer
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 *
Your answer
FOR ANY OF THE CONDITIONS CHECKED ABOVE, PLEASE LIST THE DIAGNOSIS AND EXAMINING PHYSICIAN:
Your answer
Are you under the care of a physician, chiropractor or other health care professional? if yes, please list name and number of provider *
Your answer
Are you taking any medications? if yes, please list (N/A if none) *
Your answer
Please list any allergies you may have (N/A if none) *
Your answer
Has your doctor ever said your blood pressure was too high? *
Required
Has your doctor ever told you that you have a bone or jointproblem that has been or could be made worse by exercise? *
Required
Are you over the age of 65? *
Required
Are you unaccustomed to vigorous exercise? *
Required
Is there reason not mentioned why you should not follow a regular exercise program? if yes, please explain:
Your answer
Have you recently experienced any chest pain associated with either exercise or stress? If yes, please explain:
Your answer
PLEASE CHECK THE BOX THAT DESCRIBES YOUR CURRENT HABITS
Smoking *
Alcohol *
Caffeine *
Nutrition *
Activity *
Activity before 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: *
Your answer
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: *
Your answer
Baseline Testing: (DPI STAFF ONLY)
Push up Test (1 min) ____________
Sit up Test (1 min) _____________
Squat Test (1 min) _____________
Stork Test for balance (30 sec) R: ___ L: ___ Seated Trunk balance test (30 sec) ________ Transfer Testing: _________________
Get up & Go Test: ________________ 6MWT: _________________________ Berg balance test: _______________ Body Measurement: (use form) Body Fat percentage: ____________ Weight: _______________
Client/Trainer Agreement
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 not subject to the 3% convenience fee.

Cash payments are also acceptable

2. Scheduling

Sessions are to be made by appointment only to reserve your time slot. Appointments can be made in person or by phone, but only with the assigned trainer.

Sign ups are required for all classes at dpi, you can sign up on our 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.

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
Participant Electronic signature-Print full name to accept *
Your answer
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