Small Group Training Questionnaire

Name Name First Last
Date Date / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Phone Phone - ### - ### ####
Email
CWID
OSU Affiliation

OSU Affiliation Undergraduate Student Graduate Student Medical Student Resident Faculty/Staff Other
Which campus would you like to receive personal training at?

Which campus would you like to receive personal training at? Tahlequah-CN CHS-Tulsa
Method of Payment

Method of Payment Cash Bursar (Student Only)
Emergency Contact Information
Name Name First Last
Relationship
Phone Phone - ### - ### ####
Email
Participants

Please list the other participants in your small group
Name 1 Name 1 First Last
Name 2 Name 2 First Last
Name 3 Name 3 First Last
Name 4 Name 4 First Last
Name 5 Name 5 First Last
How many sessions would your group like to purchase? (All group members will need to purchase the same amount of sessions)
1. Do you prefer working with
2. If you prefer a particular trainer, please specify
3. How many days per week would you prefer to meet with your trainer?
4. Would you prefer Virtual Training?

4. Would you prefer Virtual Training? Yes No
Availability
Prefer Day Prefer Day / MM / DD YYYY
Prefer Time

Prefer Time Morning Noon Afternoon
Fitness History and Goals

(Please be as detailed as possible)
1. Please describe your current and/or previous exercise experience
Maximum of 1200 characters allowed. Currently Entered: 0 characters.
2. Do you plan to exercise in addition to personal training sessions?

2. Do you plan to exercise in addition to personal training sessions? Yes No
If yes, how many times per week?
3. What primary health goals would you like your program to focus on? (Please choose all that apply)

3. What primary health goals would you like your program to focus on? (Please choose all that apply) Weight loss Cardiovascular Endurance Muscular Strength Flexibility Muscular Endurance Balance/Stability Other
4. Please specify any forms of exercise you know you cannot do.
5. Have you ever begun an exercise program but not followed through? If so, what were contributing factors to not finishing the program?
Maximum of 1200 characters allowed. Currently Entered: 0 characters.
6. Do you smoke or have you quit smoking in the last 3 months?

6. Do you smoke or have you quit smoking in the last 3 months? Yes No
7. Do you have a hernia/other condition that could be aggravated by lifting weights?

7. Do you have a hernia/other condition that could be aggravated by lifting weights? Yes No
8. Are you currently pregnant or less than 3 months postpartum?

8. Are you currently pregnant or less than 3 months postpartum? Yes No
Physical Activity Readiness Questionnaire (PAR-Q+, OSHF, 2017)

Please read the 7 questions below carefully and answer each one honestly
1. Has your doctor ever said that you have a heart condition OR high blood pressure?

1. Has your doctor ever said that you have a heart condition OR high blood pressure? Yes No
2. Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

2. Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? Yes No
3. Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

3. Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). Yes No
4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? Yes No
If yes, please list condition(s)
5. Are you currently taking prescribed medications for a chronic medicalcondition?

5. Are you currently taking prescribed medications for a chronic medicalcondition? Yes No
If yes, please list medication(s) and condition(s)
6. Do you currently have (or have had in the past 12 months) a bone, joint, or soft tissue (muscle, tendon, or ligament) problem that could be made worse bybecoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.

6. Do you currently have (or have had in the past 12 months) a bone, joint, or soft tissue (muscle, tendon, or ligament) problem that could be made worse bybecoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. Yes No
If yes, please list condition(s)
7. Has your doctor ever said that you should only do medically supervised physical activity?

7. Has your doctor ever said that you should only do medically supervised physical activity? Yes No
If you answered “no” to all of the previous questions, you are cleared for physical activity without medical clearance. You may skip to the end, read and sign the agreement.

If you answered “yes” to ANY of the previous questions, you will need to obtain medical clearance from your physician before participating in a personal training program.
If you answered “yes” to ANY of the above questions, please read the 8 questions below carefully and answer each one honestly
1. Do you have arthritis, osteoporosis, or back problems?

1. Do you have arthritis, osteoporosis, or back problems? Yes No
If yes, please specify condition(s)
2. Do you currently have cancer of any kind?

2. Do you currently have cancer of any kind? Yes No
If yes, please specify condition(s)
3. Are you receiving radiotherapy or chemotherapy?

3. Are you receiving radiotherapy or chemotherapy? Yes No
4. Do you have a heart condition that is difficult to control with medication or other physician-prescribed therapies?

4. Do you have a heart condition that is difficult to control with medication or other physician-prescribed therapies? Yes No
If yes, please specify condition(s)
5. Do you have Type I or Type II Diabetes, Pre-diabetes, or any other metabolic condition?

5. Do you have Type I or Type II Diabetes, Pre-diabetes, or any other metabolic condition? Yes No
If yes, please specify condition(s)
6. Do you have asthma or any other respiratory condition?

6. Do you have asthma or any other respiratory condition? Yes No
If yes, please specify condition(s)
6. Do you have asthma or any other respiratory condition?

6. Do you have asthma or any other respiratory condition? Yes No
If yes, please specify condition(s)
7. Have you ever had a spinal cord injury?

7. Have you ever had a spinal cord injury? Yes No
8. Have you ever had a stroke?

8. Have you ever had a stroke? Yes No
Please list any other medical conditions you may have that are not included in this form.
Cancellation Policy: The client must notify the trainer at least 24 hours prior to the session if he/she wishes to cancel or reschedule. If the client does not notify the trainer at least 24 hours prior to the session, he/she may knowingly forfeit that session and will not be eligible for a refund.

Expiration Notice: All small group training sessions will expire one year from date of purchase. If the client does not use all of their sessions within that year, he/she knowingly forfeits the remaining sessions and will not be eligible for a refund.

All Small Group training sessions are NON-REFUNDABLE.

Release and Indemnity Agreement: I hereby release the Board of Regents at Oklahoma State University and all its employees from all claims on account of injury which may be sustained while participating in this program, and I agree to indemnify the Board of Regents of Oklahoma State University and its employees for any claim which may hereafter be presented as a result of such injuries.
Name Name First Last
Date Date / MM / DD YYYY
Please check this box if you agree to and understand all information stated above

Please check this box if you agree to and understand all information stated above I Understand and Agree

Small Group Training Questionnaire

Small Group Training Questionnaire

Emergency Contact Information

Participants

Availability

Fitness History and Goals

Physical Activity Readiness Questionnaire (PAR-Q+, OSHF, 2017)