CHAPTER 15

BUSINESS FORMS

15 - 1

NEW LEADS AND REFERRALS

No.
1.

Date

Source

Name

Phone

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15 - 2

Apt.

Comments

15 - 3

CLUB

NAME

NAME
ADDRESS

TELEPHONE LOG
DATE
PHONE

APPT. DATE

15 - 4

NAME

PHONE

SOURCE

CLUB ___________________________________________
APPOINTMENT
DATE / TIME

SHOW

ENROLL

COMMENTS
REFERRALS

DATE__________________________

INFORMATION REGISTER

INTRODUCTORY WORKOUT PROTOCOL CHECKLIST

Prepare clipboard prior to clients arrival. Clipboard should include:
Signed Client Questionnaire and Informed Consent
Preprinted Workout Card
Body Composition Breakdown Form
Have client complete Health History Questionnaire and sign Release Form on the Client Profile and/or
Informed Consent form before the workout and fitness assessment testing.
Review questionnaire to identify any serious medical conditions. If any medical conditions are present,
ask them if their doctor has given them a medical clearance to exercise. If not, do not precede with testing
or workout. Advise them to obtain a written clearance from their doctor before the introductory workout.
You may use the medical release form in your manual.
Review their goals and reasons for pursuing a Fitness Program.
Perform Postural assessment and fitness testing. Give feed back on their results and mention how your
professionally planned, scientifically designed nutrition and supplementation programs will help them to
reach their goals.
Write clients name on standardized introductory workout card and proceed with workout.
Take member through a 5-10 minute warm up and explain importance of a warm up.
Focus on the client! Ask them about their jobs, hobbies, family etc.
Take client through each exercise. Demonstrate the exercise first. Emphasize importance
of positioning, form, technique, execution, mental focus, proper breathing and the safety features of
each machine.
Demonstrate stretches for each major muscle group at end of session.
During workout mention the various components of a successful fitness program. Each is critical in
reaching their goals. (i.e. strength training, cardio training, flexibility training, nutrition, supplementation
etc.) In order for them to address each component properly and thoroughly, they need to be educated by
you over a period of time. (Weeks or Months)
The benefits include:
A long term and permanent investment in their health. They will look and feel better!
Fitness education can be used for the rest of their lives.
Your guidance, support and motivation
Confidence in a weight room setting
Proper exercise form and technique
A professionally designed program to help them achieve their goals!
At the end of your workout thank them for giving you the opportunity to work with them. Ask them if
they are ready to get started with you today on a program.
If answer is Yes, complete your transaction and paperwork.
If answer is no, make notes on your intro tracking Sheet, and file it. Be sure to follow up within the first
week of their intro session.

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Contract No. ____________________________

Date _________________________________________

Name: ___________________________________________________________________________________________
Address: _________________________________________________________________________________________
City: _________________________________________ State _________________ Zip __________________________
Birthday ______/______/_______

Sex

Name of Gym ____________________

Male

Female

Occupation __________________________________________

Phone: (Home) ___________________________________ (Work) ___________________________________________

Body Wt. ____________ Body Fat% ____________ Height _______________

1.

Primary Training and Nutrition Objectives (check one or more)

Fat Loss

Strength

Weight Loss

Build Muscle

Shape and Tone

Injury Rehabilitation

Sport-specific training

Reduce Stress

Increase Cardiovascular Endurance

2.

How serious is your commitment to accomplishing these goals? ____________________________________________________

3.

What areas of your body do you specifically want to work on? ______________________________________________________

4.

Is there a specific time frame in mind?_________________________________________________________________________

5.

Training Experience:
Sedentary
Upper-Intermediate

6.

Beginner
Advanced

Do you presently engage in physical activity?

Intermediate
Pre-Contest or Preseason

Yes

No

What kind? ______________________________________________________________________________________________

How often? ______________________________________________________________________________________________
7.

Are you currently participating in a structured resistance-training program?

Yes

No

For how long? ____________________________________________________________________________________________

8.

Are you currently participating in a structured cardio-respiratory program?

Yes

No

For how long? ____________________________________________________________________________________________

9.

How often will you workout per week (circle one)

3 (minimum)

10

Other ________________________________________________________________

10. What kind of cardiovascular activity do you enjoy most?

Elliptical

Stationery Bike

Stationery Rower

Stair Climber

Treadmill

Aerobics Class

Other ________________________

11. Do you have an exact plan to obtain your goals? _________________________________________________________________

12. How long have you been thinking about starting a workout program? _________________________________________________

1.

What is your current occupation?___________________________________________________________________

2.

Does your occupation require extended periods of sitting?

3.

Does your occupation require extended periods of repetitive movement?

4.

If you are a student, specify the subject you are studying: _______________________________________________

5.

How many hours do you work or go to school? _______________________________________________________

6.

On a scale from 1 to 10, what is your stress level? ______________________ Personal? ______________________
15 - 6

Yes

No
Yes

No

1.

How many hours of sleep do you get per day? (average) ___________________________________________________________

2.

Have you ever suffered from insomnia?

3.

How many meals do you eat daily? ____________________ How many calories? _______________________________________

Yes

No

Do you eat meat?

Yes

No

Favorite Food: __________________________________________________

Do you snack?

Yes

No

Favorite Snack: _________________________________________________

Do you have any dietary restrictions or allergies?

Yes

No

If yes:

What? ___________________________________________________________________________________________________
What type? _______________________________________________________________________________________________
Are you currently taking a multivitamin, mineral or other type of food supplement?

Yes

No

If yes:

What are you taking? _______________________________________________________________________________________

Why? ___________________________________________________________________________________________________
4.

Do you smoke?

Yes

No

If yes: How Much? ________________________________________________

Do you ingest alcohol?

Yes

No

If yes: How Much? ________________________________________________

Do you drink coffee?

Yes

No

If yes: How Much? ________________________________________________

Are there any habits you would like to change? __________________________________________________________________

Would you like to know what supplements would be integral to your success?

Yes

No

Please check, if applicable, any of the following health problems you have or have had that have been diagnosed or
treated by a health professional.
Orthopedic Problems

Heart Murmur

Varicose Veins

Injuries to back, knees, ankles

High Blood Pressure

Lung Disease

Brain Concussion/Head Injury

Heart Attack/Stroke

Rheumatic

Loss of Consciousness

Heart Rhythm Abnormality

Dizziness

Epilepsy

Any type of heart problem

Problems with Balance/Vertigo

High Stress

Disease of Arteries

Hypoglycemia

Chest pain of any kind

High Cholesterol

Arthritis, what kind? __________________________________________________________________________________________________

Diabetes, how long ago? ______________________________________________________________________________________________
Allergies, (Hay Fever/Asthma) __________________________________________________________________________________________
Operations, what kind? _______________________________________________________________________________________________

Old or recent injuries? ______________________________________________________________________________________

When was your last complete physical exam? ___________________________________________________________________
Are you currently taking any medications? _____________ What kind? _______________________________________________
Is there any good reason not mentioned here why you should not follow an activity program even if you wanted to?
________________________________________________________________________________________________________

Have any of your blood relatives (brothers, sisters, parents, grandparents, aunts, uncles, etc.) had:
Heart Attack

High Blood Pressure

Diabetes

Congenital Heart Disease

Heart Operation

High Cholesterol

Epilepsy

Other ________________

I, the undersigned, have read, understand, and have answered the above health/medical survey questions fully and truthfully. I am aware of my responsibility to consult with
my personal physician regarding my medical fitness to engage in strenuous exercise and a nutritional support program. I do hereby intend to be legally bound for myself and
waive release of any and all rights and claims for damages I may have against the participating training facility, and the fitness trainer administering this instrument for any and
all injuries suffered while following the training and/or nutrition program provided to me.

Client's Signature _________________________________________

Print Client's Name ________________________________________
Parent/Legal Guardian's Signature* ____________________________
*If client is under 18 years of age, the parent or legal guardian must sign.

15 - 7

Date_________________

MEDICAL RELEASE
You are required to get a physical examination by a physician prior to
participating in any exercise program.
Physician Approval:
I give medical approval to the person named below to participate in the fitness assessment and
exercise program which will include exercises (aerobics, flexibility, and resistance training) for conditioning the body. I certify that the person whose name is listed below appears to have no reason why
an exercise program should not be undertaken with the recommendations I have indicated below.
Please contact me if there are any concerns.

I authorize the below named physician to release information necessary

to the development of my fitness program to:
_______________________________________________________________
Name of Patient

______________________________________________

Signature _________________________________ Date _______________

Note to the Physician

If the person named above is taking any form of medication which might effect their
response to exercise, please indicate below the type of medication, possible effects
precautions when exercising.

and

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Physician Name _________________________________ Phone _________________

Physician Signature _____________________________ Date ___________________

15 - 8

INFORMED CONSENT FORM

I , (print name) ________________________________________ give my consent to participate

in the physical fitness evaluation program conducted by _______________________.

Benifits
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 and endurance.
Risks
Risks
I recognized that exercise carries s
come risk to the musculoskeletal 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. The testing
will consist of completing this health inventory, taking a step test or bicycle ergometer test for cardiovascular
fitness, and being tested for muscular fitness and body composition.
I further understand that such screening is intended to provide the ______________________________
with essential information used in the development of individual 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
__________________________, and that I waive the responsibility of this center if I should incur any
injury as a result of my negligence.

Signed: _________________________________________ Date: ___________________________

Witness:_________________________________________ Date: ___________________________

15 - 9

BODY FAT ANALYSIS

Name

Age

Current Body Fat %___________________

Target Body Fat %____________________

Current Weight _______________________

Target Weight _______________________

Current Lean Weight _________________________

Target Lean Weight ___________________

Sex

ABOUT BODY FAT

Body fat measurements is now considered an important factor in assessing nutritional status and level of general fitness. It has
much more meaning than weight alone since the height-weight charts do not take into account body composition. For example,
many professional athletes are virtually solid muscle, yet are classified as obese by the height-weight charts. Conversely, a
person who satisfies the chart criteria can be over-fat and in poor physical condition.
While there are many ways to estimate percent body fat, the procedure of underwater (hydro-static) weighting is generally
accepted as the standard against which other methods, including skin fold values, are compared. However, underwater
weighing is tedious, expensive, and does not lend itself to mass screening application. Skin fold measurements represent a
viable alternative.

You can use percent body fat values to estimate fitness levels as following:

BODY FAT %
LEVEL

MEN

WOMEN

EXCELLENT

<11

<16

GOOD

11-13

16-19

ACCEPTABLE

14-20

20-28

21-25

29-32

25+

32+

MODERATELY UNACCEPTABLE
UNACCEPTABLE

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TRAINING PROGRAM
Date:
CLIENT:
AEROBIC:
WEIGHTS:
EXERCISE

MUSCLE

15 - 11

SEAT

WEIGHT

REPS

TRAINING PROGRAM
FITNESS EVALUATION
Name _____________________________________
DOB ____________

Date __________________________

Phone No. (Home) ______________.

(Work) _________________

A. MEDICAL INFORMATION
1. Cardiovascular
Heart Disease_____________ Family History_______________
High Blood Pressure _______
Family History _______________
Pulmonary Disease/Asthma __________________________
Comments ________________________________________________________________________
2. Orthopedic
Cervical ______ Thoracic _______ Lumbar_______ Sacro _____
Hip __________ Knees _________ Ankles ______ Feet ______
Shoulders ____ Elbows ________ Wrists _______ Hand ______
Comments ________________________________________________________________________
3. Miscellaneous
Medications:
Prescription ________________________________
Over the counter ____________________________
Allergies _____________________________________________
Surgeries ____________________________________________
B. GOALS
1.
Strength _________________________________________
2.
Tone _________________________________________
3.
Build _________________________________________
4.
Cardiovascular endurance________________________
5.
Sport-Specific Training _____________________________
6.
Injury Rehabilitation ________________________________
C. TESTING
1.
2.
3.
4.

5.

Resting Heart Rate __________________________________________________

Resting Blood Pressure _______________________________________________
Weight ___________________________________________________________
Circumference ___________________________________________________
Biceps __________________
Thigh _______________________
From Knee ___________________
Chest__________________
Calf _________________________
Waist __________________
Hips _________________________
Body Fat % ____________________
MEN
WOMEN
Biceps
___________________
Biceps
___________________
Triceps
___________________
Triceps
___________________
Subscapular
___________________
Subscapular
___________________
Total
___________________
Total
___________________

6. Cardiovascular Endurance
MAX HR = 220- _______ (AGE) = beats/min.
Target HR = MHR X 60% TO 85% = _____ beats/min.
3 MINUTES STEP TEST
Recovery rate (60 sec.) __________ (Locate pulse within 5 sec)
7.

Flexibility

Sit and Reach ___________________________

8.

Muscular endurance

Crunches ______________
Push-Up
Regular ____________ Modified ______________

Test Administered by___________________________________ Date __________________________

15 - 12

15 - 13

Total

15 - 15

15 - 16

Self-Myofacial Release (Foam Roll Tenderness Scale)

Overall Tenderness Scale:1-19
Calves

R#:

L#:

Hip Flexors

R#:

L#:

Medial Calf

R#:

L#:

Lateral Hamstrings

R#:

L#:

Lateral Calf

R#:

L#:

Medial Hamstrings

R#:

L#:

Peroneals

R#:

L#:

Sacrum

Anterior Tibialis

R#:

L#:

Lumbar region

Vastus Lateralis

R#:

L#:

Thoracic region

Vastus Medialis

R#:

L#:

Cervical Region

Iliotibial Band

R#:

L#:

Lats

R#:

L#:

Glutes

R#:

L#:

Chest

R#:

L#:

Hip Rotators

R#:

L#:
15 - 17

COMPARATIVE ANALYSIS OF THE LOWER EXTREMITY

1.

Dorsi flexion: 10 - 20

R:________ L:________

2.

Plantar Flexion: 45 Gastocnemius: Client lies supine. Axis is the ankle. Start at neutral
with leg straight and measure.
R:________ L:________
Soleus: Bend the leg and check ROM.
R:________ L:________

3.

Inversion: 30 Client is supine.

R:________ L:________

4.

Eversion: 20 Client is supine.

R:________ L:________

5.

Popliteal angle test: 170 (Straight leg hamstring test is normal at 80)
R:________
Support the clients leg at the knee,have client straighten their leg.
L:________

6.

External rotation: 45 R:_____ L:_____ Internal rotation - 35 - 40 R:________ L:________

Perform this test with your client in prone or supine. Their legs are bent at the knee for 90
both tests.

7.

Hip Flexion: 90 - 120

Client bring both knees to chest. Find Greater Trochanter and axis of the knee.
Compare one side to the other by performing single knee to chest test. 125
Right:_________________

Left:_________________

8.

Hip Extension: 15 - 30 R:________ L:________

Client is prone. Watch pelvis doesnt elevate.

9.

Abduction: 30 - 45 R:________ L:________

Client is prone.

10. Adduction: Cross midline - 30 R:________ L:________

Client is prone.
11. Hip Flexors and Rectus Femoris ( single-joint or two-joint) R:________ L:________
Thomas test. Client is supine with one knee at the chest and the other suspended over the
bench. Check lordosis in standing and then compare to kneeling.
Comments: ______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

15 - 18

COMPARATIVE ANALYSIS OF THE UPPER EXTREMITY

Shoulder Joint
1.

Shoulder Flexion: 160 - 180 R:________ L:________

2.

Horizontal Flexion: 135 R:________ L:________

3.

Shoulder Extension: 40 - 60 R:________ L:________

4.

Horizontal Extension: 45 R:________ L:________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

5.

Shoulder Abduction: 160 - 180 R:________ L:________

________________________________________________________________________________

6.

Shoulder Adduction: 50 - 75 R:________ L:________

________________________________________________________________________________

7.

Internal and External Rotation: 90 R:________ L:________

________________________________________________________________________________

8.

Scapulo-Humeral Rhythm: 1 of Scapular motion to 2 Gleno-humeral motion (Compare

symmetry of both sides.) R:________ L:________

Elbow Joint
1.

Flexion: 135 - 160 R:________ L:________

2.

Supination: 90 R:________ L:________

3.

Pronation: 90 R:________ L:________

4.

Carrying angle: R:________ L:________

15 - 19

15 - 20

15 - 21

15 - 22

15 - 23

15 - 24

15 - 25

PERSONAL DATA CHART

Name __________________________________________________________

Phone _____________________

Address _________________________________________________________________________________________
Date _______________________ Location ___________________________ Date of Birth _____________________

1. Goals:

Lose Weight
______ Lbs
Increase Stamina ______
Build Muscle
______

Lower body fat percent ______ %

Reduce Stress
______
Tone Muscle
______

2. What DIETS have you tried before?

With previous diet(s) did you encounter any of these obstacles?
Boredom
Loss of Interest
Feeling Deprived
Cheating
Loss of Energy
3. Describe your current NUTRITION/EXERCISE habits:
In an average week, how many times do you exercise? _____________ For how long? _______ hrs
What type of activities do you prefer?
Weight Training
Walking/Treadmill
Aerobics
Running/Treadmill
Bike
Others ____________________
Do you experience:
Fatigue
Headaches
Drowsiness
Digestive Difficulties
Do you crave for:
Sugar
Salt
No
Do you eat breakfast regularly?
Yes
Do you skip meals to lose weight?
Yes
No
Do you eat on the run?
Yes
No
Are you happy with the way you look?
Yes
No
Are you too tired to exercise?
Yes
No
Do you have any difficulty sleeping?
Yes
No
Are you currently taking nutrition supplements?
Yes
No
If so, what kind? ______________________________
How many meals do you eat each day? ___________
Would you be interested in learning about nutritional supplements to:
Burn Fat
Boost Metabolism
Gain Weight
Build Muscle
Control Sugar
Have More Energy
Other _________________________
EAT

DRINK

SMOKE

OTHER

___________
___________
___________
___________

When I am bored, I
When I am depressed, I
When I am nervous, I
When I am angry, I
4.

What are the reasons you want to improve yourself? _______________________________________________

_________________________________________________________________________________________
Is there a special event in our life that prompted you to join a gym or lose weight?
If yes, what event?
Wedding

Date _____ /_____ /______

Graduation

Date _____ /_____ /______

Family/School Reunion

Date _____ /_____ / ______

Ended Relationship

Date _____ /_____ /______

Actor/Model Need photos

Date _____ /_____ /______

Getting Ready for Summer

Date _____ /_____ /______

Just Had Baby

Date _____ / _____ /______

Future Athletic Event

Date _____ /_____ /______ Want to Tone up/ Strengthen Date _____ / _____ /______

15 - 26

From

Date _____ / _____ /______

15 - 27

15 - 28

PERSONAL TRAINING AGREEMENT

NO. __________

Name: _______________________________________________________________________________________
Address: _____________________________________________________________________________________
City: _____________________________________ State: ________________________ Zip: _________________
Home Phone (

) ______________________

Work Phone (

) _______________________

I, _____________________________________ agree as follows:

A. Take a_________ week program consisting of __________ nutritional analysis, ___________ personal
training sessions, ____________nutritional counseling sessions, ___________fitness evaluation,
_____________starter package, ________ retest at completion, for $______________.
B. This program shall be completed within (7) days of _________________, ________.
C. Any programming not used within the prescribed time shall be forfeited.
D. I acknowledge that _____________________________ is an Independent Contractor and that
_______________________________ is solely responsible for all services rendered.
E. All programs are nonrefundable and nontransferable.
F. All appointments must be canceled at least 24 hours in advance or you will be charged for the full
amount of that session.
G. There will be a $15.00 charge on all returned checks.

Method of Payment
Cash
Check

ATM

Amex

MC

VISA

DISC

You the buyer, may cancel this agreement at any time prior to midnight of the
business day of this studio after
the date of this agreement, excluding Sundays and holidays. To cancel this agreement, mail or deliver a signed and
dated notice or telegram which states that you, the buyer, are canceling this agreement.
Such notice shall be sent to:

_________________________________
_________________________________
_________________________________

WARNING
The use of steroids to enhance strength or growth can cause serious health problems; it may prevent teenagers from
growing to full height; and may cause damage to liver function; may also be a causal factor in heart disease and
strokes, hair loss, acne, personality changes, unwanted breast tissue, fertility problems, in addition to civil or criminal
prosecution for use, exchange or possession of a controlled substance (anabolic steroids).

Customer Signature __________________________________________ Date _____________________________

Company Agent______________________________________________________
Arrangements _________________________________________________________________________________
Receipt of a copy of this agreement is hereby acknowledged ____________________________________________

Rev. 10/2006

15 - 29

INTRO TRACKING SHEET

DATE

NAME

PHONE

15 - 30

ADDITIONAL INFORMATION

START DATE

PROGRESS REPORT

________________

COMPLETION DATE ________________

CLIENT NAME ________________________________________________________________AGE ______________ HEIGHT _______________

HOME PHONE _____________________________________________ WORK PHONE________________________________________________
CURRENT BODY COMPOSITION
______________ LBS. BODY FAT
______________ LBS. LEAN MASS

STARTING WEIGHT
__________ LBS.
INTERMEDIATE WEIGHT GOAL __________ LBS.
ENDING WEIGHT GOAL
__________ LBS.
RESULT
__________ LBS.

ON COMPLETION

PROTEIN

______________ LBS. BODY FAT

______________ LBS. LEAN MASS

CARBS

CURRENT BODY FAT

INTERMEDIATE BODY FAT
ENDING BODY FAT GOAL
RESULT

FAT

__________
__________
__________
__________

%
%
%
%

SUPPLEMENTS

% TOTAL CAL.
IDEAL

BLOOD PRESSURE ______________CHOLESTEROL ____________ HDL _______ LDL _______

MEDICATIONS ____________________________________________________________________
____________________________________________________________________
ALLERGIES
____________________________________________________________________
OTHER
____________________________________________________________________
___________________________________________________________________
DATE BODY FAT
WEEK#

WEEK

DATE

NECK

WEIGHT

SHOULDER

CHEST

WAIST

HIPS

R-THIGH R-CALVES R-BICEPS

SUPPS
JOURNAL WATER EXERCISE MENU BICEP TRICEP BACK
PLAN
Y/N RECORDER

WEEK 1
WEEK 2

WEEK 3

WEEK 4

WEEK 5

WEEK 6

WEEK 7

WEEK 8

WEEK 9

WEEK 10

WEEK 11

WEEK1 2

15 - 31

R-FORE
ARMS

TOTAL
INCHES

ILIAC TOTAL % LBS LBS

BF LM

15 - 32

DATE

TIME

CLUB
GUEST NAME

DATE
TRAINER'S NAME

GUEST REGISTER
CODE