Qualtrics Survey | Qualtrics Experience Management

Fitness Assessment Form

Last Name:

First name and middle initial (i.e. John T.):

Email:

List your phone number (***-***-****):

List your date of birth (i.e. 1/1/2000):

Select your classification:

Student
Graduate Student
Faculty/Staff Member
CR Community Member

Emergency contact (First and Last name, phone number, relationship to them)

General Availability

General Availability
	6:00am - 10:00am	10:00am - 2:00pm	2:00pm - 6:00pm	6:00pm - 10:00pm
Monday	6:00am - 10:00am	10:00am - 2:00pm	2:00pm - 6:00pm	6:00pm - 10:00pm
Tuesday	6:00am - 10:00am	10:00am - 2:00pm	2:00pm - 6:00pm	6:00pm - 10:00pm
Wednesday	6:00am - 10:00am	10:00am - 2:00pm	2:00pm - 6:00pm	6:00pm - 10:00pm
Thursday	6:00am - 10:00am	10:00am - 2:00pm	2:00pm - 6:00pm	6:00pm - 10:00pm
Friday	6:00am - 10:00am	10:00am - 2:00pm	2:00pm - 6:00pm	6:00pm - 10:00pm
Saturday	6:00am - 10:00am	10:00am - 2:00pm	2:00pm - 6:00pm	6:00pm - 10:00pm
Sunday	6:00am - 10:00am	10:00am - 2:00pm	2:00pm - 6:00pm	6:00pm - 10:00pm

Specific Times of Availability for Monday (if applicable).

Specific Times of Availability for Tuesday (if applicable).

Specific Times of Availability for Wednesday (if applicable).

Specific Times of Availability for Thursday (if applicable).

Specific Times of Availability for Friday (if applicable).

Specific Times of Availability for Saturday (if applicable).

Specific Times of Availability for Sunday (if applicable).

Preferred Assessment Location

South Campus Recreation Center
Click to write Choice 2
Click to write Choice 3

List health/medical history below (chest pain while exercising, heart disease, high blood pressure, asthma, arthritis, any aches and pains, smoking, depression, etc).

If you listed any health conditions above, list more specific below information your trainer may need below.

List any past operations (and the dates) or hospitalizations (and the dates).

List any known physical limitations or known diseases below.

Are you currently exercising regularly? If yes, describe below. If no, please type "No".

PAR-Q (Physical Activity Readiness Questionnaire)

PAR-Q (Physical Activity Readiness Questionnaire)
	Yes	No
Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor?	Yes	No
Do you feel pain in your chest when you do physical activity?	Yes	No
In the past month, have you had chest pain when you were not doing physical activity?	Yes	No
Do you lose your balance because of dizziness or do you ever lose consciousness?	Yes	No
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?	Yes	No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?	Yes	No
Do you know of any other reason why you should not do physical activity?	Yes	No

All assessments will take place at the South Campus Recreation Center. Assessments will include: four posture grid photos (which will only be seen by you, the trainer, and the trainer's supervisor), body circumference measurements, body mass index (BMI) and percent body fat calculations, along with various exercises to assist in determining any deficiencies in movement patterns. These exercises include: stretching, walking, squatting, lunging, modified pushups, resistance band pull apart, dumbbell bench press, and crunches. List any concerns with the assessment criteria listed or let us know if you prefer to only have body circumference, BMI and percent body fat measurements taken.

Medical clearance may be required for individuals who meet or exceed certain risk factors prior to the first training session. In the event medical clearance is necessary for participation, you will be required to present the Department of Campus Recreation with the provided form, signed and completed by your physician.

I acknowledge I have read and answered all the registration form questions honestly and to the best of my knowledge. I also acknowledge I will let my Personal Trainer know if my medical status changes before our first assessment or at any time during the duration of time my sessions start until the end of my sessions.

Package Completion Policy: Participants have 150 days from the date of purchase to complete all sessions purchased. Failure to do so will result in the forfeiture of the remaining sessions.
Individual Session Cancellation Policy: Individual sessions must be canceled at least 24 hours before your scheduled training time. Failure to cancel or to show up for a scheduled session will result in the loss of your training session. Please contact your trainer directly to cancel a session.
Package Cancellation/Refund Policy: To cancel the remaining sessions of a purchased package and receive a refund in the amount of the unused sessions, the participant MUST produce a medical excuse for requesting a refund or postponing sessions until medically cleared. Once purchasing and beginning sessions refunds will not be issued without medical rationale.

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