Transcript PRE-SCREENING QUESTIONNAIRE

70 Kunyung Road
Mt Eliza VIC 3930
0417 363 930
0416 238 500
Facebook: The Boiler Room
Web: www.theBoilerRoom.net.au
Welcome to The Boiler Room Wellbeing Centre
Donna Day & Janet Kosovac
would like to extend a very warm welcome to you & offer you the following health & wellbeing services:

Personal Training: highly personalised training for singles & pairs – general health & fitness, corporate
wellness, weight management, strength, sports conditioning, older adult and pre/post natal wellness

Micro Group Training: all our micro group sessions have a maximum of 6 participants to promote an intimate &
supportive environment. Sessions are conducted indoors & outdoors in our picturesque location by the bay that offers
an abundance of training possibilities:
 “Boost” Camp: A medium to high intensity early morning session designed to “boost” fitness, energy levels,
endurance & well being Mon – Fri 6-7am
 “S.P.I.C.E” Fitness Training: A “spicey” mix of modified Stretch, Power, Interval, Core & Endurance Mon – Fri
9-10am & 2-3pm
 “Grey Power” Older Adults Wellbeing: A class specifically catering to the over 60’s & designed to improve
cardiovascular fitness, muscle mass, strength, endurance & bone mass Mon – Fri 10-11am
 ‘Yummy Tummies” Pre/Post Natal Wellbeing: A customized program that incorporates safe, varied &
enjoyable exercises, pelvic floor strengthening, Pilates/yoga elements, breath work, meditation & relaxation
techniques Pre Natal: Tue & Thur 11am – 12pm Post Natal: Mon – Fri 11am-12pm
 “Weigh 2 Go” Weight Management Program: safe & effective exercises, dietary guidance & weekly weigh
ins for accountability Mon – Fri 12-1pm

Wellness Coaching: 12 week program “Be The Best You Can Be” optimise your potential, performance,
relationships & life through our face to face/phone/Skype coaching service which can be tailored to suit your
requirements, includes vision & goal setting, decisional balance & problem solving, wellness book & workbook.
Visit our website at http://www.theboilerroom.net.au/ or login to your Facebook account & search for “The Boiler Room”
(look for our logo) for more info, pictures, timetable & private health insurance rebate information
We look forward to being able to assist you with your health & wellbeing goals. In order for us to do so we ask that you
complete & return the following documentation prior to attending your first session or fitness appraisal – your
right to privacy is our prime concern – the information obtained will be treated as confidential and will not be released to
anyone without your consent:
1.
2.
3.
4.
5.
6.
Getting to Know You
PAR-Q & ACSM Initial Risk Stratification
Pre Fitness Test/Exercise Medical Warning
Medical Clearance
Notification of Indemnity
Fee Schedule/Terms & Conditions (Office Copy)
1. Getting to Know You
Name: ………………….............................. Age:…….. Height: ..........cm D.O.B…………. Sex: M / F
Address:……………………………………………………………………………………………..
Phone: (H)………………………..(B)……………………………..(M)…………………………..
Email: ……………………………………………………………………………………………….
(this email address will be used to forward all correspondence including fitness appraisal/weigh in data unless we are otherwise advised)
Emergency Contact: ………………………………………………Phone……………………….
Name of regular doctor: ………………………………….... Phone:…………………………………
Do you engage in any regular exercise/sport? If yes please specify?
..........................................................................................................................................................
What are your fitness goals (Circle)
Body fat reduction
Muscular definition
Muscular strength
Body building
Cardiovascular fitness
Well being/Self Esteem
Increased flexibility
Social
Stress Reduction
Other:.................................................................................................................................................
Do you have any exercise preferences?
…………………………………………………………………………………………………………………
Please list any exercise equipment you have in your own home (Private PT clients only)
………………………………………………………………………………………………………………..
What is your short term fitness goal (6-8 weeks)
…………………………………………………………………………………………………………………
What is your long term fitness goal (12 months)
………………………………………………………………………………………………………………..
Please circle which type of training you are interested in attending:
Personal Training:
Single
Pairs
Micro Group Exercise:
Boost Camp
S.P.I.C.E.
Yummy Tummies
Grey Power
Weigh 2 Go
Corporate:
Fitness
Teambuilding
Wellness Coaching:
Singles
Couples
Groups
Corporate (3.5 hr workshop, 5 x 1 hr workshop or
(12 x 1 hour face to face or via Skype)
12 x 1 hour workshop )
Date Starting: ..............................................................
Session Day/s:
Mon
Tue
Session Times:
......... am/pm
..........am/pm ........am/pm
How would you prefer to pay:
Casual
Wed
10 pack
Thur
Fri
.........am/pm
.........am/pm
Monthly
Do you agree to photos of yourself being used for promotional purposes
YES
NO
2. PAR-Q & ACSM INITIAL RISK STRATIFICATION
Please allocate 1 point to each yes answer
Questions
Score
Risk Factors
Are you male and 45 or older or are you female and 55 or older?
Do you have a family history of heart disease, heart attack, bypass surgery, angioplasty, stroke, or sudden death prior to the age of
55 (male) or 65 (female)?
Have you smoked cigarettes in the past 6 months?
Is your usual blood pressure >=140/90 or do you take BP medication?
Is your LDL (bad) cholesterol > 130 (3.4mmol-L-1) or is your HDL (good) cholesterol < 40 for men or 50 for women (1.3mmol-L-1) or
is your total cholesterol >= 200 (5.5mmol-L-1) or are you on lipid lowering medication or you do not know what your levels are?
Is your fasting glucose >=6.1mmol/L or you do not know what your fasting glucose is?
Is your weight/height2 (BMI) >=30? or is your waist girth measurement >100cm?
Are you taking any other medication and if so what is it for? ..............................................................................................................
Do you have any hormonal imbalances & if so please describe? .......................................................................................................
Do you get less than 30 mins of moderate physical activity most days of the week?
TOTAL RISK FACTOR SCORE
Symptoms
Do you ever have pain/discomfort in your chest or surrounding areas?
Do you ever feel faint/dizzy other than when sitting up rapidly or lose consciousness?
Do you ever find it difficult to breathe when you are lying down or sleeping?
Do your ankles become swollen (other than after a long period of standing)?
Do you ever have heart palpitations, or unusual periods of rapid heart rate?
Do you ever experience pain in your legs – intermittent claudication?
Has a physician ever said you have a heart murmur/condition and/or that you should only do exercise prescribed by a doctor?
Do you feel unusually fatigued/breathless with usual activities?
TOTAL SYMPTOMS SCORE
Other
Do you have any of the following diseases: heart condition/disease, chronic obstructive pulmonary disease (emphysema or chronic
bronchitis), asthma, interstitial lung disease, cystic fibrosis, diabetes, thyroid disorder, renal disease or liver disease or any other
cardio, pulmonary or metabolic disease &/or are you on medication for any of the above conditions?
Do you have any bone/joint problems, such as arthritis or a past injury that might get worse with exercise? If so please describe
Do you have a heavy cold or flu, or any other infection/infectious disease?
Are you pregnant or have you given birth within the past 8 weeks?
Do you have any other problem that might make it difficult/unsafe for you to exercise? If so please describe
TOTAL OTHER SCORE
Low risk = (men<45 women<55) & no more than 1 risk factor – can do maximal test/vigorous exercise without medical clearance
Mod risk = (men>45 women>55) or any age + 2 or more risk factors – Moderate test/exercise only (medical clearance for vigorous)
High risk = 1 or more Symptoms or Other - no testing/exercise without medical clearance – please use enclosed form
Name:…………………………………..
Signature: …………………………..
N.B. Please advise your trainer if any of the above information changes
Date:. ……………..
3. Pre Fitness Test/Exercise Medical Warning
RELATIVE CONTRAINDICATIONS
ABSOLUTE CONTRAINDICATIONS
Left main coronary stenosis (narrowing of
coronary artery)
Moderate stenotic valvular heart disease
(narrowing of mitral valve)
Electrolyte abnormalities such as hypokalemia
(decreased serum potassium levels) or
hypomagnesemia (decreased serum magnesium
levels)
Severe arterial hypertension (resting BP
200/110)
Tachyarrhythmia (rapid, irregular heartbeat) or
bradyarrhythmia (slow, irregular heartbeat)
Hypertrophic cardiomyopathy or other forms of
outflow obstruction
Ventricular aneurysm (sac like protrusion from
heart)
Neuromuscular, musculoskeletal, or rheumatoid
disorders exacerbated by exercise
Uncontrolled metabolic diseases such as
diabetes, thyrotoxicosis (excessive thyroid
hormone) or myxedema (hypothyroidism
characterised by relatively hard oedema of
subcutaneous tissue)
Chronic infectious diseases such as
mononucleosis, hepatitis or AIDS
Recent significant change in resting ECG suggesting significant
ischemia (restricted blood flow to the heart), recent (within 2 days)
myocardial infarction (death of heart tissue caused by insufficient
blood supply), or other acute cardiac events
High risk unstable angina (chest pain)
Uncontrolled cardiac/ventricular/atrial arrhythmia (irregular
heartbeat) causing symptoms or compromised cardiac function
Acute congestive heart failure
High/third degree atrio/ventricular (AV) heat block (slow heart rate
& fainting)
Severe symptomatic aortic stenosis (narrowing of aortic valve
opening)
Uncontrolled symptomatic heart failure (right ventricular failure,
decreased venous flow to lungs)
Acute system/pulmonary embolus (occluded vessel caused by a
detached clot, mass of bacteria or foreign body)
Acute/active/suspected myocarditis (inflammation of heart tissue)
or pericarditis (inflammation of the membrane surrounding the
heart and major blood vessels)
Suspected or known dissecting aneurysm (splitting of an arterial
wall by blood entering through a tear, commonly in the aorta, near
the aortic valve)
Intra cardiac thrombi/thrombophlebitis
Acute infections or significant emotional stress/psychosis
If you have any of the abovementioned conditions please circle them (or another medical
condition not listed) and obtain medical clearance from your doctor prior to any fitness
test or exercise program commencing.
Avoid eating, drinking, stress, caffeine, alcohol &/or exercise 2 hours prior to any fitness test
Fitness tests will be stopped if the following signs & symptoms appear: abnormal ECG changes,
blood pressure &/or heart rate responses or equipment malfunction
Be sure to advise your PT if you experience nausea, dizziness, lack of breath &/or pain during a
fitness test or during exercise.
This form & the PAR-Q form are not intended to put you off beginning your health &
fitness program but are used to gather important information which will be used to
develop an appropriate fitness appraisal format and/or exercise program/session making
sure that the tests/programs are relevant and that any injuries and your medical history,
goals & preferences are taken into account. If you have any difficulties completing these
forms please do not hesitate to ask for our assistance.
Name: .................................................. Signature: .............................................. Date: ..............
4. MEDICAL CLEARANCE
To Whom it May Concern,
Re:
Client Name: …………………………………………….
This client has been sent to you to gain a medical clearance to participate in a fitness test/program.
Medical Clearance:
Please select one of the following options:
This client is able to participate in any fitness related activity/program at your facility
This client may participate in fitness activities at your facility based on the following guidelines:
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………..
Patient’s last blood pressure reading: …………./…………….
Patient’s last cholesterol reading:
………………………….
Please indicate by your signature below that your patient is medically cleared to participate in
fitness tests/training.
………………………………….
Print name of physician
….…………………………..
Signature of physician
………………….
Date
Physician’s phone: (…..) ………………………….
Please contact either Donna Day on 0417 363 930 or Janet Kosovac on 0416238500 if you have
any concerns in relation to your patient’s participation in the program.
5. NOTIFICATION OF INDEMNITY
Please read and sign the following:
I ………………………………………......….. of ……………………………………………………………..........................
understand and accept that:
• there exists the possibility that certain abnormal changes and risks may occur during training or testing sessions
• I am responsible for monitoring my own condition throughout the tests and training sessions, and should any
unusual symptoms occur, I will cease my participation and inform the trainer of the symptoms. Efforts will be made to
minimize these occurrences by preliminary screening and/or precautions & observations during the testing or training.
• the possibility may and does exist that accidental or unavoidable discomfort or injury may occur
• I should obtain a medical clearance before undertaking fitness testing and/or training if:
I.
I have or have had any medical condition and/or;
II.
I am above the age of 45 (male) or 55 (female) and/or;
III.
the PAR Q – ACSM Initial Risk Stratification score indicates that I am classified as high risk and
I wish to take part in submaximal (moderate) fitness testing/training or;
IV.
the PAR Q – ACSM Initial Risk Stratification score indicates that I am classified as moderate risk
and I wish to exercise at a vigorous level (higher than moderate);
• in the event that a medical clearance is required, it is my responsibility to ensure this clearance is obtained and that
failure to do so is at my own risk.
• that without a medical clearance, Namaste PT and/or Inspirational Fitness may decide no further training of myself
can take place until such medical clearance is obtained.
• this clearance will be treated as privileged and confidential, as will all other personal details and that these will not
be released or revealed without my express written consent.
• in the event of injury or illness, whilst in attendance at a Namaste PT and/or Inspirational Fitness appraisal &/or
training session, I give my permission for a representative of Namaste PT and/or Inspirational Fitness to make
decisions on my behalf concerning the most appropriate action to be taken with respect to my condition.
•as part of their commitment to maintaining a high level of Occupational Health & Safety Management, the Melbourne
Business School requires me to sign this form indemnifying the School from responsibility or liability associated with
the use of The Boiler Room gymnasium facilities and/or School grounds. And that furthermore the management of
the School reserves the right, at its absolute discretion, to suspend any activity deemed to jeopardise the health or
safety of any person or persons. If the School management believes that this activity could affect the smooth running
of the School’s business, its reputation, security or safety, it reserves the right to intervene and/or suspend the
activity.
•as a client of Namaste PT and/or Inspirational Fitness, that individual acts can and do affect the whole School
community and that the School will not tolerate behaviour that impedes fellow clients of the School or exposes them
to discrimination or harassment, and that the School will maintain its duty of care at all times and will take all
reasonable and practicable steps to ensure the safety of clients and staff from accident or injury.
In signing this form, I affirm that I have read it in its entirety and that all my questions regarding the testing and
proposed exercise regime have been answered to my satisfaction. My participation is totally voluntary, I know that I
can discontinue my participation at any time without penalty. I agree to assume the risk of such testing and exercise,
and further agree to hold harmless Namaste PT and/or Inspirational Fitness and/or Melbourne Business School and
their subsidiaries, affiliates, employees, agents and any other persons associated from any and all claims, suits,
losses, or related causes of action for damages, including, but not limited to, such claims that may result from my
injury or death, accidental or otherwise arising in any way from the testing or exercise regime.
Participant Signature: ……………………………………………… Date ………………………
Witness Signature: ……………………………………. ………….. Date …………………………
6. BOILER ROOM FEE SCHEDULE – OFFICE COPY
as of 1/7/11
Service
Casual
10 pack
12 pack
Workshop
1
p/w
2
p/w
3
p/w
4
p/w
5
p/w
Singles
70
600
-
-
-
-
-
-
-
Pairs
60
500
-
-
-
Micro Group Exercise
20
-
-
-
60
120
180
240
300
Grey Power Only
20
-
-
-
40
80
120
160
200
-
-
600
-
-
-
Personal Training
Paid
monthly
-
Wellness Coaching
Singles & Couples
Combine wellness coaching with a PT 10 pack
& save $200 p.p. per package
Group & Corporate
(min 4 and max 20):
3.5 hour workshop
200
-
-
-
-
-
PLEASE CIRCLE YOUR PREFERRED OPTION
TERMS & CONDITIONS
1. All fees shown are $ per person
2. Micro Group Exercise fees (other than casual) are per person per month and must be paid at the beginning of
each month to secure your place
3. Clients paying on a casual basis must pre-book prior to attending to secure their place in the session.
4. Personal Training clients receive a training journal, calorie counting book, tailored program, regular fitness
appraisals & SMS reminder service.
5. The Weigh 2 Go weight management program requires a training journal & calorie counting book which can be
purchased through us for $35 and a heart rate monitor which can be purchased online.
6. Namaste PT & Inspirational Fitness reserve the right to close on weekends, public holidays, during part of the
school holidays and/or due to Melbourne Business School closures – in the latter instance alternative venues will
be organised or appropriate fee adjustments/package deferrals will be provided by Namaste PT/Inspirational
Fitness at their discretion
7. If requested, client services may be deferred for other reasons at the discretion of the trainer
8. Cancellations made within 24 hours prior to training will not be refundable or transferable
9. In the event a client is late, the session will conclude at the pre-set time so as not to inconvenience other clients
10. No shows without notice are subject to a 3 strike policy – in this instance a training place will be held for 3 weeks
and then offered to other clientele.
11. Melbourne Business School staff receive 50% discount on all training services
12. Payments must be made prior to training and can be made via cash, cheque or direct deposit (preferred) to:
If you are training with Donna:
Account Name: Namaste PT
Bank: Commonwealth Bank
Account No: 10253055
Branch: Mt Eliza
BSB: 063 550
If you are training with Janet:
Account Name: Inspirational Fitness
Bank: Commonwealth Bank
Account No: 10132809
Branch: Dromana
BSB: 063 822
Please use your name & session type as the online banking reference
I have read the enclosed information and I understand & agree to the fees, terms & conditions set down by Namaste
PT & Inspirational Fitness
Signed by client: ……………………………………. Date: ………………………………..
BOILER ROOM FEE SCHEDULE – CLIENT COPY
as of 1/7/11
Service
Casual
10 pack
12 pack
Workshop
1
p/w
2
p/w
3
p/w
4
p/w
5
p/w
Singles
70
600
-
-
-
-
-
-
-
Pairs
60
500
-
-
-
Micro Group Exercise
20
-
-
-
60
120
180
240
300
Grey Power Only
20
-
-
-
40
80
120
160
200
-
-
600
-
-
-
-
200
Personal Training
Paid
monthly
-
Wellness Coaching
Singles & Couples
Combine wellness coaching with a PT 10 pack
& save $200 p.p. per package
Group & Corporate
(min 4 & max 20):
3.5 hour workshop
-
-
-
-
-
TERMS & CONDITIONS
1. All fees shown are $ per person
2. Micro Group Exercise fees (other than casual) are per person per month and must be paid at the beginning of
each month to secure your place
3. Clients paying on a casual basis must pre-book prior to attending to secure their place in the session.
4. Personal Training clients receive a training journal, calorie counting book, tailored program, regular fitness
appraisals & SMS reminder service.
5. The Weigh 2 Go weight management program requires a training journal & calorie counting book which can be
purchased through us for $35 and a heart rate monitor which can be purchased online.
6. Namaste PT & Inspirational Fitness reserve the right to close on weekends, public holidays, during part of the
school holidays and/or due to Melbourne Business School closures – in the latter instance alternative venues will
be organised or appropriate fee adjustments/package deferrals will be provided by Namaste PT/Inspirational
Fitness at their discretion
7. If requested, client services may be deferred for other reasons at the discretion of the trainer
8. Cancellations made within 24 hours prior to training will not be refundable or transferable
9. In the event a client is late, the session will conclude at the pre-set time so as not to inconvenience other clients
10. No shows without notice are subject to a 3 strike policy – in this instance a training place will be held for 3 weeks
and then offered to other clientele.
11. Melbourne Business School staff receive 50% discount on all training services
12. Payments must be made prior to training and can be made via cash, cheque or direct deposit (preferred) to:
If you are training with Donna:
Account Name: Namaste PT
Bank: Commonwealth Bank
Account No: 10253055
Branch: Mt Eliza
BSB: 063 550
If you are training with Janet:
Account Name: Inspirational Fitness
Bank: Commonwealth Bank
Account No: 10132809
Branch: Dromana
BSB: 063 822
Please use your name & session type as the online banking reference