Re-Align Exercise Therapy Data Questionnaire/ Intake Form
Intake and Medical History
Email address *
How did you hear about Re-Align Exercise Therapy?
Your answer
Date:
MM
/
DD
/
YYYY
PERSONAL INFORMATION
Name:
Your answer
Address
Your answer
Date of Birth
MM
/
DD
/
YYYY
Sex
Home Phone/ Cell Phone
Your answer
Receive Text Messages
Emergency Contact and Phone Number
Your answer
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE
PAR-Q is designed to help you help yourself. Many health benefits are associated with regular exercise. Completing PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people, physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide in answering these few questions.
Has a Physician ever said you had heart trouble?
Do you frequently have pains in your heart or chest?
Do you often feel faint or have spells of severe dizziness?
Has a physician ever said your blood pressure was too high?
Has a physician ever said you have a bone or joint problem?
Is there any good physical reason not mentioned here why you shouldn't start an exercise program even if you wanted to?
Are you over 65 and not accustomed to vigorous exercise?
MEDICAL HISTORY
Have you had any of the following?
Heart Attack?
Bypass or Cardiac Surgery?
Chest Discomfort with Exertion?
High Blood Pressure?
Rapid or Runaway Heart Beat?
Skipped HeartBeat?
Rhuematic Fever?
Phelebitis or Embolism?
Shortness of Breath with Exercise?
Fainting or Lightheadedness?
Pulmonary Disease or Disorder?
High Blood Fat Lipid Levels?
Stroke?
Diabetes?
Do you or have you ever smoked?
Are you or were you pregnant in the last 3 months?
Recent Hospitalization for an cause?
Orthopedic Problems?
Cancer?
For any of the above questions you answered yes, please give diagnosis and examining doctor?
Your answer
Please list any and all medications or supplements you are taking?
Your answer
Do you have any other health issues not mentioned above?
Your answer
Do you have any previous injuries or limitations not listed above?
Your answer
Do you have any current pain?
If so, state the location, severity, duration, and onset?
Your answer
What position increases the pain?
Your answer
What position decreases the pain?
Your answer
Do you have trouble sleeping due to pain?
What time of day are you in the most pain?
Do you feel better or worse with movement?
Does your job require any of the following?
EXERCISE HISTORY
Are you currently working out? If yes, describe.
Your answer
Do you have a history of exercising?
Your answer
What is your primary reason for joining this program?
Your answer
How much time can give to doing a daily menu?
Your answer
POLICIES
1. Patient will be required to complete this form prior to receiving a fitness assessment.
• Data Questionnaire
• PAR-Q
• Medical History
• Exercise History
• Policies
• Informed Consent/Liability Waiver

2. If patient has any of the following physical conditions, it is required to have a medical clearance from their physician.
• Yes to any questions on the PAR-Q
• Men over 55, Women over 65.
• Hypertension (>130/90mm Hg)
• Hyperlipidemia (cholesterol greater >220 mg/dl)
• Diabetes
• Family history of heart disease prior to age 60

3. Payment is expected prior to the start of each training session or session package. All paid sessions are non- transferable and non-refundable. Time slots are available on a “first come, first served” basis by appointment.

4. Regarding cancellations:
• All qualifying cancellations will result in a credit being given which can be applied to a future session.
• All cancellations must be made with a minimum of 24 hours advance notice in order to receive credit for the session. Due to an inability to fill the previously blocked time period, cancellations with less than 12 hours notice given will not qualify for a credit and client will be charged for the session.
• If a client misses an appointment, they will be deemed a “no show” and be charged full price for the session.

5. Clients have the right to terminate a particular exercise or workout at any time. You are in control of your workouts. If an exercise is uncomfortable or painful, or if you want to stop for any reason, you may do so. If a particular exercise is painful or you have an injury or other limitation that makes it difficult for you to do, let us know and we will substitute another exercise.

6. The more compliant you are in doing what your trainer has asked of you, the faster you will reap results. If you are not compliant and do not do the exercises consistent enough you will not see the results you want.

7. Re-Align Exercise Therapy respects your privacy and anything that you tell us will be kept confidential. All of your personal information is for our records only and will not be shared or distributed to any third party.
Electronic Client Signature
Your answer
Date
MM
/
DD
/
YYYY
CONSENT FOR PHYSICAL FITNESS/ LIABILITY WAIVER
General Statement of Program Objectives and Procedures:

I understand that this physical fitness program may include exercises to build the cardio respiratory system (heart and lungs), the musculoskeletal system (muscle endurance and strength, and flexibility), and to improve body composition (lean/fat ratio). Exercises may include aerobic activities, calisthenics, and high intensity conditioning drills and resistance training to improve muscular strength and endurance, speed and agility drills as well as flexibility exercises to improve range of motion and reduce risk of injury to muscle. It is recommended that all participants obtain medical clearance from their physician before engaging in any fitness program.

Description of Potential Risks:

I understand that the reaction of the heart, lung, and blood vessel system to such exercise cannot be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart rate, ineffective functioning of the heart, and in rare instances, heart attacks. Use of the weightlifting equipment, performing agility drills and engaging in body calisthenics, although very rare, can lead to muscle strains, pain, and injury.

Release of Liability:

I have read and understand the information presented here. I am fully aware of my right to ask any questions at any time or to discontinue participation in any activities. I have been informed of the importance of a medical clearance from a physician before participating in any fitness programs. In the rare event that any of the above risks do occur I hereby release Re-Align Exercise Therapy from any and all liability as outlined above resulting from participation in such activity.
Electronic Client Signature
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy