SILVER STAR FITNESS - QUESTIONNAIRE
Matthew Stretton
Certified Master Personal Trainer
380 Cobbitty Rd Cobbitty
M 0419 288 050 T 4651 1111
E matt@silverstarfitness.com.au
W silverstarfitness.com.au
Name Height Starting Weight
Address P/Code
Phone Mobile D.O.B Occupation
Email Emergency Contact Name Phone
Reasons why I want to train ( tick below )
I want to lose weight I want to increase muscle tone I want to be fitter I want to build muscle mass
I want to get stronger Rehabilitation I want to feel healthier in general  
My main goal for training is
PLAN
• In what time frame would you like to achieve your goals ? ( e.g 3 months, Wedding )
• How much time each week are you able to dedicate to exercising ?  
• What training style best describes your personality ? ( please tick )
Lack motivation / need to be pushed Motivated / happy to set your own pace  
Highly motivated / want to be pushed to the limit  
• What time of day / days of the week best suits you?
Early morning 6am-8am Mid morning 9.30am - 12 midday Afternoon 2pm - 6pm Evening 6pmk - 9pm
Mon Tues Wed Thurs Fri Sat
History
Do you have any medical conditions that inhibit your training ability ?

HEALTH
Assess your health needs by writing either Yes or No
Have you had ?
Heart attack Heart surgery Pace maker Heart failure Heart valve disease Heart transplant
Congenital heart disease  
Symptoms -
• Do you experience - Chest discomfort with exertion Breathlessness Dizziness, fainting, blackouts
Other health items
• Do you: Take prescription medications Take heart medication Currently pregnant Trying to conceive
If you answered Yes to any of the above questions you may need written clearance from your health professional
Assess your cardiovascular risk by writing Yes or No
Are male over 45 years Are postmenopausal Are you a smoker Have BP > 140/90mmHg
Take BP medication Have high cholesterol  
Family history of heart attack Diabetic - Type 1 Type 2 Have epilepsy Have asthma
If you answered Yes to 2 or more of these questions you may need written clearance from your health professional. If you did not, That’s Awesome!
HOW DO YOU FEEL
How energetic do you feel on a regular basis? (Tick a Number)
From - Just want to sleep Energiser bunny  
How healthy do you feel?
From - Kill me now Doctor - what’s that!  
How fit do you feel?
From - Stairs scare me Can run all day  
How strong do you feel?
From - Can’t open milk Can lift a car  
Performance Measures (optional)
Resting H/R Your resting B/P  
Measurements
Waist Chest Hip Arm Thigh  
Calf Bicep  
LIFESTYLE
What sports or ways to exercise do you enjoy ?
What are some of your favourite foods ?
What do you expect from your exercise programme ?

Any comments you would like to make ?


ACKNOWLEDGEMENT RELEASE AND ASSUMPTION OF RISK
Warning - This is an important document, which affects your legal rights and obligations. Please read it carefully and do not sign it unless you understand it. If you have any questions please ask.
Participant Name DOB
( if under 18yo, parent or guardian to sign also )
Parent / Guardian DOB
Address Phone
Postcode
Acknowledgement of Risks, Injury and Obligations
• I acknowledge that the activities I am to undertake have potential dangers and by participating in them I am exposed to certain risks.
• I acknowledge and understand that whilst participating in any such activities:
• I may be injured, physically, mentally, or may die. • Any physical conditions I may have, of which I may or may not be aware, of which I may or may not have disclosed to Silver Star Fitness or its staff and trainers, may be aggravated or worsened by my participation. • My personal property may be lost or damaged. • Other persons participating in such activities may cause me injury or damage my property. • I may cause injury to other persons or damage their property. • The conditions in which activities are conducted may vary without warning. • There may be no or inadequate facilities for treatment or transport of me if I am injured.
• I assume the risk of, and the responsibility for any injury, illness, death or property resulting from my participation in any activities.
Release and Indemnity to Silver Star Fitness and its’ staff and trainers
• In consideration of the acceptance of my payment or ( guest status ) for participating in any activity ( and except to the extent that the same may be precluded by statute ) I agree to release and indemnify Silver Star Fitness and staff and trainers as follows:
• I participate in the activities at my sole risk and responsibility.
• I release, indemnify and hold harmless Silver Star Fitness and its’ staff and trainers, from and against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of or arising out of injury, loss, damage, or death caused by me or my property in any way, whatsoever. I also agree that in the event that I am injured or my property is damaged, I will bring no claim, legal or otherwise, against Silver Star Fitness in respect of that injury or damage.
• I acknowledge that I have either had a physical examination and been given my physician’s permission to participate, or that I have decided to participate in the activity and use of the equipment without the approval of my physician and assume all responsibility for my participation, and utilisation of equipment during the activities.
• I acknowledge and agree that no warranties or representations have been made to me by Silver Star Fitness or its’ staff and trainers regarding the results I will or may achieve from any programme conducted by Silver Star Fitness. I understand that results are individual and may vary.
Before signing this document I have read and understand it and know how it affects my legal rights.
Signed by Date
Where the Participant is under 18 years of age
Before signing this document I have read and understand it and know how it affects my legal rights.
I, being a parent or legal guardian of the person named in this,
Acknowledgement and Release hereby acknowledge and agree:
• I have read the whole document and understand it.
• I consent to the person, named in this acknowledgment and release, participating in the activity and I am aware of the risks, dangers and obligations set out above in the acknowledgement and release.
• In consideration of the person named in this acknowledgement and Release being accepted to participate in any activity
• I agree to release and indemnify Silver Star Fitness, its staff & trainers, in the same manner and to the same effect and extent as if it were the person first named in this acknowledgement and Release and the person participating in any of the activities.
Signature of Parent/Guardian Date