Sabrina Otani

KIN 2210

Client-Care Package
Sabrina Otani
KIN 2210

Sabrina Otani
KIN 2210

CONSENT FORM
I, ______________, acknowledge/understand:
1) That I must fill out all the forms in this package and all the forms that the trainer/assessor
requests.
2) That all information I provide to the trainer/assessor must be truthful.
3) That there are risks that come with the following health/fitness program.
4) That if there are any changes in my health, I must inform the trainer/assessor as soon as
possible. My health is of the utmost importance to the trainer/assessor so it is important
that I keep them informed.
5) That if I experience pain/discomfort during the program, I must inform my
trainer/assessor as soon as possible.
6) That I may need to gain medical clearance by my physician if one or more of the forms in
this package or my trainer/assessor suggests I need one.
7) That the information gained (no personal information) in the program may be used in
other studies conducted by the trainer/assessor.
8) That I must perform the activity to the best of my ability.
9) That I may do the program individually or with a group.
10) The policies detailed in this consent form.
I, ______________, give consent to:
1) Perform in the following health/fitness program.
2) Allow the trainer/assessor to utilize all information I have provided to how they see fit.
3) Allow the following measurements to be taken at any time during the program:
a. Heart rate
b. Blood pressure
c. Lactate threshold
d. VO2max
4) Perform in any other measurement not mentioned above for the goodness of my health
and the program. These may include:
a. BMI
b. Anthropometric measurements (e.g. waist circumference, skinfolds, etc.)
5) Perform in any activity the trainer/assessor requests. These may include activities focused
on:
a. Musculoskeletal health
b. Cardiovascular health
c. Respiratory health
d. Flexibility
6) Allow the information gained in the activity to be compared with other individuals also in
the program.
Policies:

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KIN 2210

Cancellation policy: If a session has been planned and the client is unable to attend, the client
must cancel within 48 hours with the trainer/assessor. If they do not cancel within 48 hours of the
session, the cost for that session will not be refunded.
Unused session policy: If the client finishes the program and still has one or more sessions left in
the package they paid for, the client will gain a refund for those particular sessions based on the
package. This policy stands for a month from the clients last session completed. If the client
does not contact the trainer/assessor within a month after the last session completed, a refund
will not be given for those sessions.

I HAVE READ, UNDERSTOOD AND AM GIVING MY CONSENT TO ALL OF THE

ABOVE INFORMATION. PLEASE SIGN BELOW:

Client Signature:_____________________________

Date: _____________

Trainer Signature:____________________________

Date:______________

ADDITIONAL INFORMATION
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Clients Name: _______________________ Trainers Name: __________________________

Place of Residence:
City:

Street:

Province:

Postal Code:
Contact Information:

Home Phone Number:

Cell Phone Number:
Work Phone Number:
Email:

Emergency Contact
Number 1:
Emergency Contact
Number 2:

Name:

Emergency Contact Information:

Relationship:
Phone Number:

Relationship:

Phone Number:

Physician Information:
Number of years they have been
your physician:

Phone Number:

Office Address:

City:

I HAVE PROVIDED ALL THE INFORMATION REQUESTED ABOVE. PLEASE SIGN

BELOW:
Client Signature:_____________________________

Date: _____________

Trainer Signature:____________________________

Date:______________

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KIN 2210

ABOUT
Trainer name: Sabrina Otani
City: Mississauga, Ontario
Education: University of Guelph-Humber

Bachelors degree in Kinesiology

Diploma in Health Promotion

Contact Information:
Work: (123) 456-7890. ext: 000
Email: otanisabrina@gmail.com
Availability:
Monday to Friday: 9am 5:30pm
Saturday: 9 am 3pm
Sunday: no availability
Cost of Services:
Initial assessment = $40.00
Single session (assessment not included) = $65.00/hour
6-session package (assessment included) = $340.00 ($56.67/hour)
12-session package (assessment included)= $720.00 ($60.00/hour)
Policies:
Please view the consent form where the Cancellation and Unused Session policy are
explained.
For further information on some health-related topics, please view:
Byberg, L., Melhus, H., Gedeborg, R., Sundstrm, J., Ahlbom, A., Zethelius, B., . . .
Michalsson, K. (2009). Total mortality after changes in leisure time physical activity in 50
year old men: 35 year follow-up of population based cohort. British Medical Journal.
doi:10.1136/bmj.b688

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KIN 2210

Coburn, J.W., & Malek, M.H. (Eds.). (2012). NSCAs Essentials of Personal Training (2nd ed.).
Windsor: Human Kinetics.

DiNicolantonio , J. J. (2014). The cardiometabolic consequences of replacing saturated fats with

carbohydrates or -6 polyunsaturated fats: Do the dietary guidelines have it wrong? British
Medical Journal. doi:10.1136/openhrt-2013-000032

Loreto, C. D., Fanelli, C., Lucidi, P., Murdolo, G., Cicco, A. D., Parlanti, N., . . . Feo, P. D.
(2005). Make Your Diabetic Patients Walk: Long-term impact of different amounts of
physical activity on type 2 diabetes. Diabetes Care, 28. doi:10.2337/diacare.28.6.1295

Peluso, M. A., & Andrade, L. H. (2005). Physical activity and mental health: the association
between exercise and mood. Clinics, 60.

Conversation Topics:
Benefits of Exercise
Exercise can benefit weight control. Depending on the type of exercise you do, it will benefit in
terms of maintaining weight loss and preventing unwanted weight gain. For example, highintensity interval training is best for weight loss as opposed to low-intensity cardio training
because high-intensity will burn more calories and burning more fat. Obesity is currently a huge
problem in Canada and exercise is one of the ways that can improve their health and weight.
Exercise can benefit health conditions and diseases. If an individual has high blood pressure,
exercise can lower it. Heart rate as well can be improved with exercise. As you exercise, your
heart rate increases and this trains the heart to deliver more blood and oxygen to your muscles. If
you exercise continuously every week, your resting heart rate will lower which is a good thing.
Diabetes is a growing problem in Canada and exercise is a way that can help those with this
disease; exercise can aid in regulating blood glucose.
Obesity Rates at Historic Levels in Canada
Obesity is a huge growing problem in Canada. Currently, the Maritimes and Territories have the
highest rates from 2000 to 2011, and more than 30% of the population is estimated to be obese.
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British Columbia has the lowest overall rates in Canada at about 25%, but this percentage has
increased from 20% since 2000. Obesity is also linked to numerous chronic diseases such as
diabetes and because the obesity rates have increased more and more, the rates of chronic
diseases in these individuals has increased as well.

MEDICAL/HEALTH HISTORY AND QUESTIONNAIRE

Trainer Name: _________________________

Client Name: _________________________

Check all that apply to you.

Have you had:
A heart attack
Heart surgery
Cardiac catheterization
Coronary Angioplasty
Pacemaker/implantable cardiac
defibrillator/rhythm disturbance
Heart valve disease
Heart failure
Heart transplant
Congenital heart disease
Cancer (If so, list which one)
A surgery not listed above

A condition not listed above

Do you have these symptoms:

Pain, discomfort in chest, neck, jaw, arms, or
other areas of body
Unreasonable breathlessness at rest or with
mild exertion
Dizziness or Syncope
Heart murmur
Unusual fatigue
Orthopnea or Paroxysmal nocturnal dyspnea
Fainting/Blackouts
Do you currently have:
Heart valve disease
Congenital heart disease
Diabetes (If so, list which one)
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Asthma
Cancer (If so, list which one)
Musculoskeletal problems
A systolic blood pressure of 140mmHg or
more
A diastolic blood pressure of 90mmHg or more
A blood cholesterol level over 200mg/dL
Are you:
A man older than 45 years
A woman older than 55 years
Pregnant (If so, how many months?)
A smoker or have quit smoking within the
previous 6 months
A woman who has had a hysterectomy
A woman who is postmenopausal
Do you have any allergies? Please list if so:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you take any medications? Please list if so and for what:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you have any relatives that died before age 55 (men) and/or 65 (women)? If so, please
explain below who they are (e.g. grandfather, mother, etc.) and what they passed away
from.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What is your physical/exercise activity level?
____ Sedentary (little to no exercise)
____ Light exercise (1-3 days per week)
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____ Moderate exercise (3-5 days per week)

____ Heavy exercise (6-7 days per week)
____ Very heavy exercise (twice per day)

RISK STRATIFICATION ALGORITHM

Clients Name: ________________________________

Sabrina Otani
KIN 2210

Clients Risk Level: _____________________

RISK STRATIFICATION TESTING & SUPERVISION RECOMMENDATIONS

Clients Name: ____________________________

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Clients Risk Level: ________________

Medical Clearance needed: _____
Supervision needed: _____

For what activity (if yes): _____

For what activity (if yes): _____

RECORD SHEET
Trainer Name: _________________________

Client Name: __________________________

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Age: _____

Gender: _____

Resting Heart Rate: __________bpm

Was medical clearance needed: _____

Maximum Heart Rate: __________bpm

Blood Pressure: __________

Start Date: ______________
DATE

EXERCISE

# OF SETS

DURATION/
# OF
REPETITIONS

COMPLETED?

Warm-up:

Cool-down:
Trainers Notes:

Any pain/discomfort:
Client Signature of Completion of Session:

DATE

EXERCISE

# OF
SETS

Warm-up:

12

DURATION/
# OF
REPETITION
S

COMPLETED?

Sabrina Otani
KIN 2210

Cool-down:
Trainers Notes:

Any pain/discomfort:
Client Signature of Completion of Session:

DATE

EXERCISE

# OF
SETS

Warm-up:

Cool-down:
Trainers Notes:

13

DURATION/
# OF
REPETITION
S

COMPLETED?

Sabrina Otani
KIN 2210

Any pain/discomfort:
Client Signature of Completion of Session:

DATE

EXERCISE

# OF
SETS

Warm-up:

Cool-down:
Trainers Notes:

Any pain/discomfort:
Client Signature of Completion of Session:

14

DURATION/
# OF
REPETITION
S

COMPLETED?

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KIN 2210

References
CBC News. (2013). Obesity rates at historic levels in Canada - Health. Retrieved from
http://www.cbc.ca/news/health/obesity-rates-at-historic-levels-in-canada-1.1321955

CSEP. (2011). PAR-Q Forms. Retrieved from http://www.csep.ca/english/view.asp?x=698

Mayo Clinic. (2014). Exercise: 7 benefits of regular physical activity. Retrieved from
http://www.mayoclinic.org/healthy-living/fitness/in-depth/exercise/art-20048389?
footprints=mine

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