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Consultation

Lontech Health Defence Training Consultation Questionnaire

First name*

Last name*

Gender*

Female

Male

Date of Birth*

Day

Month

Year

Email*

Phone*

Age*

Height*

Weight*

Job Tittle*

What is the activity level of your job?

Sedentary (mostly seated)

Moderate (light activity such as walking or standing)

High (heavy labour, very active)

What is your working schedule like?*

Regular type hours (09:00 - 17:00)

Late fixed shifts (14:00 - 22:00)

Early fixed shifts (06:00 -14:00)

Graveyard shift (22:00 - 06:00)

Mixed shift patterns

Please list any physical activities that you take part in outside of the gym and work:*

If you have any diagnosed health problems list the condition(s)*

If you are on any medications, please list them.*

What additional therapies are being undertaken for the given health problem(s)?*

If you have any injuries, please list them.*

What additional therapies are being undertaken for the given injury?*

Are you experiencing any stresses or motivational problems?*

Yes

Do you suffer from diabetes, asthma, high or low blood pressure?*

Yes

Are you a current cigarette smoker?*

Yes

Your current diet could be best characterized as: (tick those which apply)*

low-fat

low-carb

high-protein

Vegetarian/Vegan

high-sugar

high-processed foods

high-fat

No special diet

Please rate your readiness for change, 1 being reluctant, 10 being I'm ready today!*

What are your reasons for training?*

Improve health

Improve endurance

Increase strength

Increase muscle mass

Fat loss

Weight gain

Life balance - Stress management

Self-defence

Develop sporting skill and performance

Injury rehab

Injury prevention

Improve flexibility

Improve posture

Improve core strength

Timeline for achieving your goal.*

6 weeks

12 weeks

24 weeks

36 weeks

48 weeks

1 year

2 year

Continuous -life style change/maintenance

How often are you willing to train a week to reach your goal?*

Please rate your motivational level to do what it takes for reach your goal. 1 being unmotivated, 10 being excited.*

How often are you currently exercising per week?*

Have you trained with a personal trainer before?*

Yes

At what times during the day would you prefer to train?*

Morning

Mid-Day

Afternoon

Evening

How many PT sessions can you commit to each week?*

What are your expectations on me as your Personal Trainer?

Where did you hear about Lontech Personal Training?*

1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Agreed session length will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

I AGREE TO THE ABOVE TERMS & CONDITIONS!

Yes, subscribe me to your newsletter.

lontech pt sophie stretch_#image30145_ed

Physical Activity Readiness

Questionnaire (PAR Q)

First name

Last name

Date of birth: * required

Address

Phone

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? * Required

Yes

Do you feel pain in your chest when you do physical activity? * Required

Yes

In the past month, have you had a chest pain when you were not doing physical activity? * Required

Yes

Do you lose balance because of dizziness or do you ever lose consciousness? * Required

Yes

Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity? * Required

Yes

Is your doctor currently prescribing medication for your blood pressure or heart condition? * Required

Yes

Do you know of any other reason why you should not take part in physical activity? If YES, please comment: * Required

Yes

Tell us about yourself...

If you answered YES to one or more questions:

You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.

If you answered NO to one or more questions:

It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.

A fitness appraisal can help determine your ability levels.

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise.

Date: * required

Note: This PAR Q becomes invalid if your condition changes so that you would answer YES to any of the 7 questions.

Thanks for submitting!

Par- Q

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