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 *
I have understood and answered all the above questions honestly During the exercise programme, every effort is made to keep the session safe and minimise the risks while providing an effective session. I am participating of my own free will and I am aware, as with any exercise programme there is a risk of injury. I understand that it is my responsibility to inform KATE CAMPBELL FITNESS of any medical conditions I have that may affect my ability to exercise safely and to update this information as and when necessary. I understand that I should not exercise if I feel unwell The structure, purpose, benefits and risks of the session will be explained throughout, and I understand that I am FREE to withdraw from the session at any point. I will not hold KATE CAMPBELL FITNESS and her staff liable in any way for injuries that may occur while I am training.
Terms and conditions *
I have read and agree to the terms and conditions available in the footer of this webpage