STARTER SESSION CARD Call 1: - Microsoft · · 2016-09-30STARTER SESSION CARD ... Angina High...
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© Ultimate NEV, LLC 2015 STARTER SESSION CARD Coach’s Name_________________________ PERSONAL INFORMATION Name: _________________________________________ Age ____________ Female / Male Occupation _____________________________ E-Mail: __________________________________________ Cell Phone #: (_______) _______________________ Today’s Date: ___________________________ PHYSICAL ACTIVITY AND MEDICAL QUESTIONNAIRE YES NO YES NO 1. Has a doctor ever said you have a heart condition and recommended only medically supervised activity? 2. Do you have chest pain brought on by physical activity? 3. Do you tend to lose consciousness or fall over as a result of dizziness? 4. Has a doctor ever recommended medication for blood pressure or heart disease? 5. Do you have a bone or joint problem that could be aggravated by the proposed physical activity? 6. Are you aware, through your own experience or a doctor’ advice, of any other physical reason against your exercising without medical supervision? 7. Are you over the age of 65 and not accustomed to vigorous exercise? If you answered YES to any of the above, please answer the following: 8. Have you consulted your physician regarding increasing your physical activity and/or performing a fitness assessment? 9. If you answered NO to question #8, will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment? □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Heart Condition Diabetes Asthma - uncontrolled Short of Breath Arthritis – Bursitis Rheumatism Hernia Recent Surgery Sacroiliac Problem Angina High Blood Pressure Knee Problems Back Problems Cervical □ Thoracic □ Lumbar □ Notes: □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ If “YES” to any of the above, please see Fitness Director before exercise is scheduled. I certify that the above statements are true and correct. I understand that a physician’s note may be requested. If a note is requested, I should NOT proceed with this workout until the note is received. Member Signature:________________________________________________________ Date:_________________________ HISTORY How long has it been since you were comfortable with your level of fitness? What has changed? _________________________________________________________________________________________ How did you feel at that time? __________________________________________________________________ CURRENT 5 PILLARS OF FITNESS PLAN 1. Nutrition: 2. Cardiovascular: 3. Strength: 4. Discipline: 5.Professional Coaching: GOALS What are your fitness goals, and why? ___________________________________________________________________________________________ __________________________________________________________________________________________ ___________________________________________________________________________________________ How long have you been thinking about achieving these goals? ________________________________________ Why have you waited to see a Coach? ___________________________________________________________________________________________ What is different this time? ____________________________________________________________________ PRIVATE COACHING & NUTRITION PROFILE Have you ever worked with a Personal Trainer? □ YES □ NO . Tell me about your nutrition: ____________________________________________________________________________________________________________________________ . What medications/vitamins/supplements do you take? ________________________________________________________________________________________________________ Call 1: _________________________ Call 2: _________________________ FD Final Call: ____________________
Transcript of STARTER SESSION CARD Call 1: - Microsoft · · 2016-09-30STARTER SESSION CARD ... Angina High...
© Ultimate NEV, LLC 2015
! ! ! !!!!
STARTER SESSION CARD Coach’s Name_________________________
PERSONAL INFORMATION Name: _________________________________________ Age ____________ Female / Male Occupation _____________________________
E-Mail: __________________________________________ Cell Phone #: (_______) _______________________ Today’s Date: ___________________________
PHYSICAL ACTIVITY AND MEDICAL QUESTIONNAIRE YES NO YES NO 1. Has a doctor ever said you have a heart condition and recommended only medically
supervised activity? 2. Do you have chest pain brought on by physical activity?3. Do you tend to lose consciousness or fall over as a result of dizziness?4. Has a doctor ever recommended medication for blood pressure or heart disease?5. Do you have a bone or joint problem that could be aggravated by the proposed
physical activity? 6. Are you aware, through your own experience or a doctor’ advice, of any other physical
reason against your exercising without medical supervision? 7. Are you over the age of 65 and not accustomed to vigorous exercise?
If you answered YES to any of the above, please answer the following:
8. Have you consulted your physician regarding increasing your physical activity and/or performing a fitness assessment?
9. If you answered NO to question #8, will you consult your physician prior to increasingyour physical activity and/or performing a fitness assessment?
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Heart Condition Diabetes Asthma - uncontrolled Short of Breath Arthritis – Bursitis Rheumatism Hernia Recent Surgery Sacroiliac Problem Angina High Blood Pressure Knee Problems Back Problems
Cervical □ Thoracic □ Lumbar □ Notes:
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□ □ □ □ □ □ □ □ □ □ □ □
If “YES” to any of the above, please see Fitness Director before exercise is scheduled.
I certify that the above statements are true and correct. I understand that a physician’s note may be requested. If a note is requested, I should NOT proceed with this workout until the note is received.
Member Signature:________________________________________________________ Date:_________________________
HISTORY 1. How long has it been since you were comfortable with your level of fitness? What has changed?
_________________________________________________________________________________________
2. How did you feel at that time? __________________________________________________________________
CURRENT 5 PILLARS OF FITNESS PLAN
1. Nutrition:
2. Cardiovascular:
3. Strength:
4. Discipline:
5.Professional Coaching:
GOALS 3. What are your fitness goals, and why?
1. ___________________________________________________________________________________________
2. __________________________________________________________________________________________ 3. ___________________________________________________________________________________________
4. How long have you been thinking about achieving these goals? ________________________________________ 5.
6. Why have you waited to see a Coach?
___________________________________________________________________________________________ 7. What is different this time? ____________________________________________________________________
PRIVATE COACHING & NUTRITION PROFILE 8. Have you ever worked with a Personal Trainer? □ YES □ NO9.
10. Tell me about your nutrition: ____________________________________________________________________________________________________________________________
11. What medications/vitamins/supplements do you take? ________________________________________________________________________________________________________
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Call 1: _________________________ Call 2: _________________________
FD Final Call: ____________________
© Ultimate NEV, LLC 2015
! ! ! !!!!
STARTER SESSION CARD Coach’s Name_________________________
EXERCISES – MOVEMENT SPECIFIC
EXERCISE ROUND 1 ROUND 2 30 DAY FOLLOW UP PUSH PUSH-UPS (20 REPETITIONS 4/2/1 TEMPO) REPS REPS REPS
NOTES:
LEGS SQUAT (20 REPETITIONS 4/2/1 TEMPO, 30 SEC HOLD) REPS REPS REPS
NOTES:
CORE PRONE ISO ABS (1 MINUTE HOLD) SECONDS SECONDS SECONDS
NOTES:
PULL REPS REPS REPS
NOTES:
CONDITIONING
NOTES:
FIT GRID - PROFESSIONAL RECOMMENDATION
What would you rank your level of commitment to this goal? (1-10) _________ !
Wee
ks
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday DESIRED WEIGHT CHANGE:
Starting Weight: _________________
Goal Weight ____________________
# of lbs.: _________ (1 -2 lbs. per week)
SESSION NEED:
Total Weeks: ___________________
Sessions/week: ________________
Total Sessions: ________________
Foundation Program ( Stability ) 1 2 3 4
Accelerated Results ( Strength ) 5 6 7 8
Guaranteed Results ( Power ) 9
10 11 12 13 14 15 16 17 18 19 20
Package Options: 1. ____________________________ 2. ____________________________ 3. ____________________________
