Fitness Assessment & Personal Trainer Request Form

Please fill out to request a Body Composition Scan, Fitness Assessment or Initial Consultation with one of our Certified Personal Trainers.

Name Name First Last
Email
A MAC Membership is required for these services. Do you have a current MAC Membership?

A MAC Membership is required for these services. Do you have a current MAC Membership? Yes No
I would like to request the following:

I would like to request the following: InBody 570 Body Comp Test = $10.00 Fitness Assessment = $20.00 Initial Consultation = $35.00 *required to hire a Personal Trainer
What day/s will work best to schedule your Body Comp, Fitness Assessment and/or sessions with a trainer (check all that apply)

What day/s will work best to schedule your Body Comp, Fitness Assessment and/or sessions with a trainer (check all that apply) Monday Tuesday Wednesday Thursday Friday Saturday Sunday
What time of day will work best to schedule your appointment (check all that apply)

What time of day will work best to schedule your appointment (check all that apply) Early Morning Morning Noon Afternoon Early Evening Late Evening
Do you have a gender preference for your trainer?

Do you have a gender preference for your trainer? Male Female No Peference
Do you want to request a specific trainer?

Do you want to request a specific trainer? Alexis Baker Noah Bowie Gihyeon Gwon Javier Rodriguez Jonathan Salinas
Health Screen Form

Three or more "yes" indicate the need for Physician's Clearance
Do you have high blood pressure?

Do you have high blood pressure? Yes No
Are you currently on medication for high blood pressure?

Are you currently on medication for high blood pressure? Yes No
Do you smoke?

Do you smoke? Yes No
Are you a former smoker?

Are you a former smoker? Yes No
If yes to the question above, please write in the date you quit.
Do you have diabetes?

Do you have diabetes? Yes No
Have any of your blood relatives had heart disease, heart surgery, or angina?

Have any of your blood relatives had heart disease, heart surgery, or angina? Yes No
Do you have any orthopedic problems that would prevent you from exercising?

Do you have any orthopedic problems that would prevent you from exercising? Yes No
If yes to the question above, please explain.
Please list any other problems that might impact your ability to follow an exercise routine.
When was your last physical exam?
Exercise History

Exercise History Sedentary (little or no weekly exercise) Moderately Active (exercise 1-3 times per week) Active (exercise 4-5 times per week) Athletic (exercise 6 or more times per week)
Please write the name and phone number of your emergency contact person.
Physical Activity Readiness Questionairre (PAR-Q)

One or more "yes" indicate the need for Physician's Clearance
Do you have a heart condition?

Do you have a heart condition? Yes No
Has your doctor recommended only medically approved exercise?

Has your doctor recommended only medically approved exercise? Yes No
Do you have chest pain while exercising?

Do you have chest pain while exercising? Yes No
Do you have chest pain while at rest?

Do you have chest pain while at rest? Yes No
Do you lose consciousness from dizziness?

Do you lose consciousness from dizziness? Yes No
Do you lose balance from dizziness?

Do you lose balance from dizziness? Yes No
Do you have any bone or joint issues that are aggravated by exercise?

Do you have any bone or joint issues that are aggravated by exercise? Yes No
Are you taking medication for a heart condition?

Are you taking medication for a heart condition? Yes No
Are you aware of any other reason you should gain medical clearance before exercising?

Are you aware of any other reason you should gain medical clearance before exercising? Yes No
If yes to the question above, please explain.
The Assistant Director for Wellness will assign a trainer to you and have them contact you to schedule your selection. If the answers to your Health Screen or PAR-Q indicate the need for Physician's Clearance that will be provided via email and you will need to bring a completed form to your appointment. Any other questions at this time may be written below or emailed directly to jroden@uta.edu

Fitness Assessment & Personal Trainer Request Form

Health Screen Form

Physical Activity Readiness Questionairre (PAR-Q)