Personal Training & Programme design Screening Form

The information collected in this form will be used only for the purpose of designing an appropriate fitness program for you and will not be disclosed to any third party without your consent.

We reserve the right to request a doctor’s clearance before allowing you to receive personal training with Kate Campbell Fitness.

Please fill all of the boxes as thoroughly as possible. By giving as much information as possible a detailed plan / programme can be developed.

Name *
State is South Yorkshire
Date of birth *
Date of birth
Please add month of birth first
Due date if pregnant
Due date if pregnant
Date baby born if postnatal
Date baby born if postnatal
What is your job
Moderate activity is sufficient to make you slightly breathless and sweaty for 20 minutes. Examples include: brisk walking, cycling, swimming etc. Please include frequency, intensity, time and type.
What mode of training do you prefer? *
What methods do you prefer? *
Preferred training environment
Preferred equipment
In the past what barriers have prevented you reaching your goal?
Are you aware of any barriers that may occur during the training programme?
What are your goals?
Have you ever had any of the following?
If yes please provide more detail in the comments box below
Coronary Heart Disease Primary risk factors
Please tick all that apply
Coronary Heart Disease Secondary Risk Factors
Any clients that fall into one or more of the following categories should see their GP for medical clearance prior to testing and exercising. • Any clients 35+ with one major risk factor • Any client under 35 years with two major risk factors
Informed consent