Client Details
Name:: Jo Fraser
Date of Birth:: 22/11/1990
Gender:: Female
Street Address:: 11 Mark St
Suburb:: Newmarket
Postcode:: 4051
Email:: [email protected]
Contact Number:: 0476796394
Occupation:: Writer
Employer: Just Media Design
Have you ever had a Personal Trainer before?:: No
Where did you hear about Epic Win PT:: Google
Medical Contact
Doctor’s Name:: Dr Jenni Dowler
Address:: Toowong Medical
Contact Phone Number::
Emergency Contact
Name:: Jenni Fraser
Contact Phone Number:: 0424727227
Relationship:: Mother
Why are you here?
What do you consider to be your number one priority?:: Weight Loss
Name two areas of your life which you are not happy with right now and would like to improve?:: Fitness and health
What has kept you from starting an exercise program:: Procrastination
Medical Backgrouund
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING:
IS THERE A FAMILY HISTORY OF ANY OF THE ABOVE CONDITIONS? IF SO, PLEASE LIST THEM:: No
HAVE YOU HAD ANY ILLNESSES IN THE LAST 12 MONTHS? IF YES, PLEASE GIVE DETAILS: No
DO YOU HAVE ANY ALLERGIES?:: No
DO YOU HAVE ARTHRITIS, ASTHMA OR HERNIA?:: No
ARE YOU TAKING ANY PRESCRIBED MEDICATIONS? IF YES, PLEASE GIVE DETAILS?:: No
Are you receiving any treatment from a doctor, physiotherapist or other health professional? If Yes – What for?:: No
Have you been hospitalized recently or given birth in the last 3 months?:: No
NECK: NO
If YES, Please elaborate::
BACK: NO
If YES, Please elaborate::
SHOULDERS: NO
If YES, Please elaborate::
HIPS: NO
If YES, Please elaborate::
KNEES: NO
If YES, Please elaborate::
ANKLES: NO
If YES, Please elaborate::
Do you have any other medical problems or conditions we should know about prior to commencing an exercise program?:: NO
If Yes – please Elaborate::
I understand the questions above & my answers are true and correct. I will not have any claim against EPIC WIN PT or my instructor for any illness, injury or adverse change in medical condition arising directly/indirectly from any program carried out.:: I Agree
BODY COMPOSITION + POSTURAL APPRAISAL CONSENT
Posture & Body Composition: I Agree
CONDITIONS OF TRAINING
THIS IS AN IMPORTANT DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS AND OBLIGATIONS. PLEASE READ CAREFULLY AND DO NOT SIGN UNLESS YOU UNDERSTAND IT. IF YOU HAVE ANY QUESTIONS, PLEASE ASK.:
LEGALLY BINDING AGREEMENT: I Agree