new client packet - City of Des Peres

personal training
NEW CLIENT PACKET
EXPERIENCE THE DIFFERENCE
The Lodge Des Peres Fitness Center
314.835.6180 Phone
314.835.6151 Fax
www.TheLodgeDesPeres.com
Daniel Boyle, Fitness Supervisor
dboyle@desperesmo.org ~ 314.835.6153
LODGE PERSONAL TRAINING- NEW CLIENT PACKET
Thank you for choosing Lodge Personal Training. We strive to assist clients in achieving their goals of
a healthier lifestyle safely!
We do require some paperwork to be filled out so that we can better serve you. This new client packet contains the following:
medical history form, an informed consent, and a physician’s approval form. Please fill out the medical history form, sign and
date the consent, and give the physician’s approval form to your doctor if directed to do so by your trainer*. Please have
these papers prepared and ready to give to your Personal Trainer during your first appointment. We do reserve the right to
refuse service if the Personal Trainer is uncomfortable training you until you receive approval from your physician, physical
therapist, or medical professional.
[*Mandatory physician’s approval results from one of the following: recent hospitalization, back, leg or joint pain or injury,
any restrictions with progressive exercise, or meeting 3 or more positive risk factors. These risk factors include, but are not
limited to: heart or blood pressure problems, diabetes, being over the age of 65, or leading a sedentary lifestyle. The Lodge
recommends that all participants beginning a new fitness program receive approval from their physician. However, it is not
mandatory.]
Proper attire for your training session includes:
Proper attire includes short-sleeved shirt, shorts or jogging pants, gym shoes and a re-sealable water bottle.
Your first training session will consist of the following:
Your first training session will be a fitness assessment and consultation with the Personal Trainer. The Trainer will do an
extensive series of tests to assess your current health and fitness level in order to develop a program that will best fit you.
Therefore, it is not recommended that you workout prior to the assessment. Be sure to eat a light meal such as fruit and
yogurt at least an hour before your appointment but please refrain from any caffeine as this will alter your assessment results.
This is also the time to discuss your goals and dreams. Remember, the Trainers are here to guide you, but it is you who must
make the commitment. Each additional training session will consist of a workout that has been uniquely designed for you.
Length of Appointment:
Each appointment is one hour in length unless otherwise noted. Packages will expire six months from the purchased date.
Promptness:
At The Lodge, we are striving to make every experience exemplary. If your Lodge Trainer is more than 10 minutes late, you
will receive a complimentary hour of training. If you are late for a session, you will be trained only for the remainder of your
scheduled training hour. If a client is more than twenty minutes late, the session could be canceled and the client will forfeit
their fees.
Cancellation Policy:
If for any reason The Lodge needs to cancel your Personal Training appointment with less than a 24-hour notice, you will
receive a complimentary appointment. In return, The Lodge requires a 24-hour notice to cancel any Personal Training
appointment. Failure to give the required time will result in forfeited fees.
Refunds:
If you are unable to continue scheduled Personal Training sessions due to medical reasons, the Fitness Supervisor will issue
you a refund. You will need to submit a letter from your doctor restricting you from exercise prior to the refund being issued.
If you have any questions about your Personal Training appointment at The Lodge, please contact the Fitness Supervisor at
314-835-6180.
Referrals:
As a new personal training client, you have taken the first step to better health. You recognize the benefits of an organized
fitness routine designed specifically with you in mind. We are excited to begin our referral program as a way to thank you.
You will receive a $25 personal training coupon for each client you refer to our Lodge personal training program that you can
apply to your next personal training package. Tell your friends about the benefits of Personal Training at The Lodge Des Peres
and SAVE! For more information about the referral program, please contact the Fitness Supervisor at 314 835-6180.
I have read the above and have asked any questions I might have in regards to the Lodge Personal Training policy and
procedures.
______________________________________________
Personal Training Client Signature
Date
MEDICAL HISTORY FORM
Answer each question by printing the necessary information.
Answers are confidential.
PERSONAL INFORMATION:
Name: _______________________________________________________________________
Date of Birth: _____________________________Age:_________________________________
Address: _____________________________________________________________________
City, State, Zip: ________________________________________________________________
Home Phone: ______________Cell Phone: _______________Work Phone: ________________
Email: _______________________________________________________________________
Employer: _______________________________Occupation:___________________________
IN CASE OF EMERGENCY, PLEASE NOTIFY:
Name: ___________________________________ Relationship: _________________________
Address: _____________________________________________________________________
City, State, Zip: ________________________________________________________________
Home Phone: ______________________________Work Phone: ________________________
MEDICAL INFORMATION:
Physician: __________________________________Phone:_____________________________
Are you under the care of a physician, chiropractor, or other health care professional for any reason? Yes / No
If yes, list reason: ______________________________________________________________
_____________________________________________________________________________
Are you taking any medications? Yes / No (if yes, complete the following)
Type Dosage/Frequency/Reason for taking:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please list any allergies: _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
MEDICAL HISTORY FORM - CONTINUED
1. Has your doctor ever said your blood pressure was too high? Yes / No
2. Has your doctor ever told you that you have a bone or joint problem
that has been or could be made worse by exercise? Yes / No
3. Are you over age 65? Yes / No
4. Are you unaccustomed to vigorous exercise? Yes / No
5. Is there any reason not mentioned here why you should not follow a regular exercise
program? Yes / No If yes, please explain: ________________________________________
___________________________________________________________________________
6. Have you recently experienced any chest pain associated with either exercise or stress?
Yes / No If yes, please explain: ________________________________________________
___________________________________________________________________________
SMOKING
Please fill in the circle that best describes your current habits:
O Non-user or former user; Date quit: __________________
O Cigar and/or pipe
O 15 or fewer cigarettes per day
O 16 to 25 cigarettes per day
O 26 to 35 cigarettes per day
O More than 35 cigarettes per day
FAMILY & PERSONAL MEDICAL HISTORY:
If there is a family history for any condition, please fill in the circle to the left. If you are
personally experiencing any of these conditions, fill the information in on the line.
O Asthma: ____________________________________________________________________
O Osteoporosis:
________________________________________________________________
O Respiratory/Pulmonary Conditions: ______________________________________________
O Diabetes: Type I: _________ Type II: __________ How Long? _________________________
O Epilepsy: Petite Mal: _________ Grand Mal __________ Other: _______________________
LIFESTYLE AND DIETARY FACTORS:
O Occupation Stress Level: Low / Medium / High
O Energy Level: Low / Medium / High
O Colds per Year: ______________________________________________________________
O Anemia: ____________________________________________________________________
O Gastrointestinal Disorder: ______________________________________________________
O Hypoglycemia: _______________________________________________________________
O Thyroid Disorder: _____________________________________________________________
O Pre/Postnatal: _______________________________________________________________
FAMILY/PERSONAL MEDICAL HISTORY - CONTINUED
CARDIOVASCULAR:
O High Blood Pressure: __________________________________________________________
O High Cholesterol: _____________________________________________________________
O Hyperlipidemia: ______________________________________________________________
O Heart Disease: _______________________________________________________________
O Heart Attack: ________________________________________________________________
O Stroke: _____________________________________________________________________
O Angina _____________________________________________________________________
O Gout: ______________________________________________________________________
MUSCULOSKELETAL INFORMATION:
Please describe any past or current musculoskeletal conditions you have incurred, such as
muscle pulls, sprains, fractures, surgery, back pain, or general discomfort:
Head / Neck: __________________________________________________________________
Upper Back: ___________________________________________________________________
Shoulder / Clavicle: _____________________________________________________________
Arm / Elbow: __________________________________________________________________
Wrist / Hand: __________________________________________________________________
Lower Back: ___________________________________________________________________
Hip / Pelvis: ___________________________________________________________________
Thigh / Knee: __________________________________________________________________
Arthritis: _____________________________________________________________________
Hernia: _______________________________________________________________________
Surgeries: ____________________________________________________________________
Other: _______________________________________________________________________
NUTRITIONAL INFORMATION
1. Are you on any specific food / nutritional plan at this time? Yes / No
If yes, please list: _______________________________________________________________
2. Do you take dietary supplements? Yes / No
If yes, please list: _______________________________________________________________
3. Do you experience any frequent weight fluctuations? Yes / No
4. Have you experienced a recent weight gain or loss? Yes / No
If yes, how much over what period of time? _________________________________________
5. How many beverages do you consume per day that contains caffeine? _________________
6. How many beverages do you consumer per week that contain alcohol? _________________
7. How would you describe your current nutritional habits?
_____________________________________________________________________________
_____________________________________________________________________________
8. Other food/nutrition issues you want to include (food allergies, mealtimes, etc.):
_____________________________________________________________________________
_____________________________________________________________________________
9. To what degree do you perceive your environment as stressful?
Work: O Minimal O Moderate O Average O Extremely
Home: O Minimal O Moderate O Average O Extremely
10. Do you work more than 40 hours a week? _______________________________________
11. Please make any other comments you feel are pertinent to your exercise program.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Signature of Personal Training Client: ________________________Date__________________
Signature of Personal Trainer: ______________________________ Date__________________
Forms provided by ISSA, International Sports and Science Association
RELEASE FORM FOR PERSONAL TRAINING
Informed Consent Form
I, ______________________________, give my consent to participate in the physical fitness
evaluation program conducted by The Lodge, in the City of Des Peres.
Benefits
Participation in a regular program of physical activity has been shown to produce positive
Changes in a number of organ systems. These changes include increased work capacity,
improved cardiovascular efficiency, and increased muscular strength, flexibility, power and
endurance.
Risks
I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and
the cardio respiratory system (dizziness, discomfort in breathing, heart attack). I hereby certify
that I know of no medical problem (except those noted on my medical forms) that would
increase my risk of illness and injury as a result of participation in a regular exercise program.
Testing and Evaluation Results
I understand that I will undergo initial testing to determine my current physical fitness status.
The testing will consist of completing this health inventory, taking a step test or bicycle
ergometer test for cardiovascular fitness, and being tested for muscular fitness and body
composition. I further understand that such screening is intended to provide my Personal
Trainer with essential information used in the development of individual fitness programs.
I understand that my individual results will be made available only to me. I also understand
that the testing is not intended to replace any other medical test or the services of my
physician. I will be provided a copy of all test results. I may share the results with whomever I
please, including my personal physician. By signing this consent form I understand that I am
personally responsible for my actions during my tenure with the Lodge Personal Training
Program and that I waive the responsibility of The Lodge Des Peres and The City of Des Peres if
I should incur any injury or death as a result of my negligence.
Signature of Personal Training Client: ________________________________ Date: _________
Signature of Witness: _____________________________________________ Date: _________
PHYSICIAN’S APPROVAL FORM
Name of Client: ________________________________________________________________
Name of Personal Trainer: _______________________________________________________
Please fill out this form releasing your patient to participate in a physical fitness program
conducted and monitored by a certified Personal Trainer. After completion of this form,
please return it to the Lodge Fitness Center. If you have any questions, please do not hesitate
to contact the Trainer at 314 835-6180. Thank you for your assistance.
Type of Activity
Intensity
Cardiovascular
____________________________
Resistance Training
____________________________
Flexibility
____________________________
Other
____________________________
Physician’s recommendations/contraindications:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________ (patient name) has been examined by me and has my approval to
participate in a progressive exercise program.
__________________________M.D.
Physician’s Signature
________
Date
FITNESS CENTER RULES
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The Fitness Center is available to everyone 16 years of age and older.
Youth, ages 14-15, will be granted admission to the Fitness Center after completion of a Youth Fitness
Orientation with a Lodge Personal Trainer. WRISTBANDS MUST BE WORN WHILE IN THE FITNESS
CENTER.
Youth, ages 12-13 will be granted admission to the Fitness Center with their parent or guardian after
both the adult and child complete a Youth Fitness Orientation with a Lodge Personal Trainer.
WRISTBANDS MUST BE WORN WHILE IN THE FITNESS CENTER and a parent must be present at all
times.
Shirts and athletic shoes must be worn at all times. No sandals or sport bras (Long tanks are
acceptable).
Please check your shoes for dirt and rocks prior to entering the Fitness Center.
Please use the lockers with locks (check out from front desk) for all personal items. The Lodge is not
responsible for lost or stolen items.
Sealed bottles or drink containers are welcome; food is not permitted.
30-minute time limit on all cardio equipment. Sign in is required. Management reserves the right to
ask you to exit the machine if you are not signed in.
Please clean the equipment when finished, spray the cleaner into the towel, NOT directly onto the
machine.
Please return all dumbbells and weight plates to the racks when finished.
All personal training sessions must be with a Lodge Personal Trainer. Trainers not employed by the
City of Des Peres may not provide their services at The Lodge.
Some cell phones interfere with the heart rate devices on the machines, so we ask that you refrain
from using them while you are in the fitness center. If you need to use your phone, please be
respectful of other members.
Common Courtesy applies - clean up your mess, return your toys and share!
TRACK RULES
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The track is available to everyone 14 years of age and older.
All users should use the inside lane - use the outside lane for passing only.
Please follow the arrow at the top of the stairs for track direction.
Youth 13 and under may use the track if accompanied by a parent or guardian.
Shirts and athletic shoes must be worn at all times.
Sealed bottles or drink containers are welcome; food is not permitted.
Strollers are permitted on the track, Monday – Saturday, 11 a.m. – 3 p.m.
Spitting is not permitted on the track at any time.
One lap equals 1/10 of a mile; 10 laps equal one mile.
The sidewalk around the outside of The Lodge equals 4/10 of a mile; 2.5 laps equal a mile.
COMPONENTS OF FITNESS & WELLNESS
Cardio/Aerobic Exercise: The training of the heart, lungs and blood system. This is accomplished by using the large
muscles of the upper legs in a continuous manner. When we walk, run, swim, bike, etc., we are improving our aerobic
component.
Recommendations:
 a minimum of 30 minutes of cardio exercise three times a week at about 70% of our target heart rate (THR).
 Since this kind of exercise is generally low intensity, it can be performed every day of the week and
sometimes more than once a day.
Our THR is determined by the following formula:
220 – your age = your maximum heart rate x 70% = THR
For those over 40:
205 – (50% x your age) = your maximum heart rate x 70% = THR
Strength: To improve overall strength, we challenge specific muscles. The best way to accomplish this is to exercise a
muscle against some form of resistance such as our body weight, free weights, cables or bands. Then employing a
recommended program of “progressive overload” we continually demand more from our muscles. They, as a result, are
forced to adapt by becoming stronger and by increasing their endurance without incurring injury.
Recommendations:
o 2-3 times per week, do not work the same muscles 2 days in a row.
o To get the most efficient workout from our machines, please be sure to adjust the “Range of Motion” and
“Axis Point” settings on all STAR TRAC equipment before each use.
o To build muscle and burn calories faster, learn to use appropriate muscle tension and breathing
techniques for each different type of exercise
Flexibility: The ability to move our limbs and/or body parts freely without constraint. Our ease of accomplishing this is a
function of our flexibility or range of motion (ROM). Flexibility is like strength: use it or lose it. An individual can lose
flexibility through failure to stretch or challenge our range of motion. The best method of improving this component is to
perform a number of stretches in a prescribed manner. Since stretching is very low intensity, we can and should stretch
every day of the week and multiple times a day.
Balance: The ability to stay centered or to remain in a desired position. Our balance is affected in two ways. First, by
affective perception, i.e., our body’s ability to sense when we are losing balance; and second, by our speed and capability
to adequately respond to our temporary loss of balance. Interestingly, this ability is a function of our strength and
flexibility. The less flexible we are, the more frequently we will lose our balance. The less strength we have, the more
diminished our capacity to regain our lost balance. There are a number of exercises we can perform to improve both
affective sensibility and corrective balance behaviors. Most of these can be performed daily.
Nutrition/Hydration: Each person is different. Your age, activity level, and body type all determine how many and what
type of nutrients your body needs. Our staff nutritionist and mypyramid.gov are both resources that can help you
determine a proper diet for your life style and fitness goals. A sample Food Pyramid from mypyramid.gov is shown on the
back of this page. This pyramid is catered towards an individual on a 2000 calorie a day diet. In addition to your nutrition
needs, it is also recommended to drink at least 64 ounces of water per day.
PERSONAL TRAINING AT THE LODGE DES PERES
314-835-6180 – WWW.THELODGEDESPERES.COM – 1050 DES PERES ROAD; 63131
- EXPERIENCE THE DIFFERENCE EXPERIENCE THE DIFFERENCE with Personal Training at The Lodge Des Peres! All of our trainers are nationally certified professionals
here to help their clients fit FITNESS into their busy lifestyles to get results. Each new client will receive a comprehensive fitness
assessment to evaluate their current level of fitness and an individualized exercise program. Payment is required before services are
rendered (Cash, Check, Visa, MasterCard and Discover accepted). Appointments and payments are taken in The Lodge Fitness Center.
NEW CLIENT 3 SESSION SPECIAL - $119
This option is available for all NEW clients to our personal training program. The new client special is 3 sessions with a personal
trainer. The first session will be a fitness assessment with the remaining two appointments executing the exercise program that has
been designed for you. This special is only available once to a new client.
ONE-ON-ONE PERSONAL TRAINING
Youth and adults can choose 60, 45 or 30 minutes to train with a nationally accredited personal trainer (30-minute sessions are
designed for youth or someone who is just beginning an exercise program and not physically ready for the intensity of more than 30
minutes, or someone who wants a specialty session such as 30 minutes of stretching). The 26-week program is designed for anyone
that wants to get serious about making some permanent changes to their lifestyle. Package includes multiple assessments, 26
training sessions in six months, nutrition tips and professional advice and technique.
MEMBER/RESIDENT
NON-MEMBER/NON-RESIDENT
INDIVIDUAL PACKAGE TYPE
60 MINUTES 45 MINUTES 30 MINUTES 60 MINUTES 45 MINUTES 30 MINUTES
01 SESSION (current clients only)
$60
$47
$33
$70
$55
$39
03 SESSION PACK
$180
$142
$99
$210
$165
$116
06 SESSION PACK
$330
$260
$182
$390
$307
$215
09 SESSION PACK
$450
$354
$248
$540
$425
$297
26 SESSION PACK*
$1275*
Not Available
$1275*
Not Available
*Payment options are available; please contact the fitness supervisor at 314-835-6180.
GROUP TRAINING – Minimum of 2 people per session, Maximum of 6 people per session
Price is per person. Group Training is great for friends, co-workers, family members wanting to get in shape together in a fun,
personalized environment. Packages are now available in 60, 45 or 30 minute length sessions.
GROUP PACKAGE TYPE
03 SESSION PACK
06 SESSION PACK
09 SESSION PACK
MEMBER/RESIDENT
60 MINUTES 45 MINUTES 30 MINUTES
$105
$83
$58
$180
$142
$99
$225
$177
$126
NON-MEMBER/NON-RESIDENT
60 MINUTES 45 MINUTES 30 MINUTES
$135
$106
$74
$240
$189
$132
$270
$216
$149
YOUTH FITNESS ORIENTATIONS - $45/Member or Resident; $50/Non-Member or Non-Resident
Youth Fitness Orientations are designed for youth ages 12-15 years wishing to use the fitness center. Youth ages 12-13 must attend
the orientation with a parent/guardian. Price is per child. Each additional child is $10, with a maximum of 5 youth per orientation.
Allow 1.25 hours for 1-2 youth and 2 hours for 3-5 youth.
COMPLIMENTARY FITNESS ORIENTATIONS – FREE FOR ALL NEW MEMBERS
Complimentary Fitness Orientations are available free of charge for all new members. The orientation is conducted by a trainer or
fitness desk associate and will orientate the member to the equipment in the fitness center as well as the procedures and policies.
We encourage all new members to participate in this service designed to assist members in getting safely started on their fitness
routines. Each orientation is 45 minutes in length. Please stop by the fitness desk or call 314-835-6180 to make an appointment
today!
OTHER SERVICES
Fitness Assessment - $70/Member or Resident; $81/Non-Member or Non-Resident
Body Fat Testing - $20/Member or Resident; $23/Non-Member or Non-Resident
Additional Nutritional Counseling Packages Available Soon
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