Readiness to change questionnaire YES

Are you looking to change a specific behavior? Are you willing to make this behavioral change a top priority? Have you tried to change this behavior before? Do you believe there are inherent risks/dangers associated with not making this behavioral change? Are you committed to making this change, even though it may prove challenging? Do you have support for making this change from friends, family, and loved ones? Besides health reasons, do you have other reasons for wanting to change this behavior? Are you prepared to be patient with yourself if you encounter obstacles, barriers, and/or setbacks? X X X

NO

Health History Form

Name _____Bernardo Aguayo_______________________________ Date ______03-10-2013____ Age _________22______________________________________________ Sex Male Physicians Name ___________________________________________________________________________ Physicians Phone (_______) __________________________________________________________________ Person to contact in case of emergency: Name __Hipolito Aguayo_______________________ Phone _______(208)878-7656__________ Are you taking any medications, supplements, or drugs? If so, please list medication, dose, and reason. __________________________________________________________________________________________ ____not currently taking any medication_______________________________________________________ __________________________________________________________________________________________ Does your physician know you are participating in this exercise program? __________yes________________________________________________________________________ Describe any physical activity you do somewhat regularly. ________running, weight lifting_______________________________________________________________ __________________________________________________________________________________________ Do you now, or have you had in the past: 1. History of heart problems, chest pain, or stroke 2. Elevated blood pressure 3. Any chronic illness or condition 4. Difficulty with physical exercise 5. Advice from physician not to exercise 6. Recent surgery (last 12 months) 7. Pregnancy (now or within last 3 months) 8. History of breathing or lung problems 9. Muscle, joint, or back disorder, or Any previous injury still affecting you 10. Diabetes or thyroid condition 11. Cigarette smoking habit 12. Obesity (BMI >30 kg/m2) 13. Elevated blood cholesterol 14. History of heart problems in immediate family 15. Hernia, or any condition that may be aggravated by lifting weights or other physical activity Yes No X X X X X X X X X X X X X X X

PAR-Q & YOU

(A Questionnaire for People Aged 15-69)
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions. Please read the questions careful and answer each one honestly: check YES or NO.

YES

NO
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? 2. 3. 4. 5. Do you feel pain in your chest when you do physical activity? In the past month, have you had chest pain when you were not doing physical activity? Do you lose your balance because of dizziness or do you ever lose consciousness? Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? 7. Do you know of any other reason why you should not do physical activity?

YES to one or more questions

If You answered
Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. Find out which community programs are safe and helpful for you. DELAY BECOMING MUCH MORE ACTIVE: If you are not feeling well because of a temporary illness such as a cold or a fever wait until you feel better; or If you are or may be pregnant talk to your doctor before you start becoming more active. PLEASE NOTE: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

NO to all questions
If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can: Start becoming much more physically active begin slowly and build up gradually. This is the safest and easiest way to go. Take part in a fitness appraisal this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.

Informed Use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for Persons who undertake physical activity, and if in doubt after Completing this questionnaire, consult your doctor prior to physical Activity.

Circulatory and Respiratory Fitness Test

Informed Consent for Exercise Testing of Apparently Healthy Adults (without known heart disease) Name _Bernardo Aguayo_____________________________________________________________ 1. Purpose and Explanation of Test I hereby consent to voluntarily engage in an exercise test to determine my circulatory and respiratory fitness. I also consent to the taking of samples of my exhaled air during exercise to properly measure my oxygen consumption. I also consent, if necessary, to have a small blood sample drawn by needle from my arm for blood chemistry and analysis and to the performance of lung function and body fat (skinfold pinch) tests. It is my understanding that the information obtained will help me evaluate future physical activities and sports activities in which I may engage. Before I undergo the test, I certify that I am in good health and have had a physical examination conducted by a licensed medical physician within the last __12___ months. Further, I hereby represent and inform the facility that I have accurately completed the pre-test history interview presented to me by the facility staff and have provided correct responses to the questions as indicated on the history form or as supplied to the interviewer. It is my understanding that I will be interviewed by a physician or other person prior to my undergoing the test who will in the course of interviewing me determine if there are any reasons that would make it undesirable or unsafe for me to take the test. Consequently, I understand that it is important that I provide complete and accurate responses to the interviewer and recognize that my failure to do so could lead to possible unnecessary injury to myself during the test. The test that I will undergo will be performed on a motor-driven treadmill or bicycle ergometer with the amount of effort gradually increasing. As I understand it, this increase in effort will continue until I feel and verbally report to the operator any symptoms such as fatigue, shortness of breath, or chest discomfort that may appear. It is my understanding and I have been clearly advised that it is my right to request that a test be stopped at any point if I feel unusual discomfort or fatigue. I have been advised that at I should, immediately upon experiencing any such symptoms or if I so choose, inform the operator that I wish to stop the test at that or any other point. My wishes in this regard shall be absolutely carried out. It is further my understanding that prior to beginning the test, I will be connected by electrodes and cables to an electrocardiographic recorder that will enable the facility personnel to monitor my cardiac (heart) activity. During the test itself, it is my understanding that a trained observer will monitor my responses continuously and take frequent readings of blood pressure, the electrocardiogram, and my expressed feelings of effort. I realize that a true determination of my exercise capacity depends on progressing the test to the point of fatigue. Once the test has been completed, but before I am released from the test area, I will be given special instructions about showering and recognition of certain symptoms that may appear within the first 24 hours after the test. I agree to follow these instructions and promptly contact the facility personnel or medical providers if such symptoms develop. 2. Risks It is my understanding and I have been informed that there exists the possibility of adverse changes during the actual test. I have been informed that these changes could include abnormal blood pressure, fainting, disorders of heart rhythm, stroke, and very rare instances of heart attack or even death. Every effort, I have been told, will be made to minimize these occurrences by preliminary examination and by precautions and observations taken during the test. I have also been informed that emergency equipment and personnel are readily available to deal with these unusual situations should they occur. I understand that there is a risk of injury, heart attack, stroke, or even death as a result of my performance of this test, but knowing those risks, it is my desire to proceed to take the test as herein indicated. 3. Benefits to Be Expected and Alternatives Available to the Exercise Testing Procedure The results of this test may or may not benefit me. Potential benefits relate mainly to my personal motives for taking the test (e.g., knowing my exercise capacity in relation to the general population, understanding my fitness for certain sports and recreational activities, planning my physical conditioning program, or evaluating the effects of my recent physical

habits). Although my fitness might also be evaluated by alternative means (e.g., a bench step test or an outdoor running test), such tests do not provide as accurate a fitness assessment as the treadmill or bike test, nor do those options allow equally effective monitoring of my responses. 4. Confidentiality and Use of Information I have been informed that the information that is obtained from this exercise test will be treated as privileged and confidential and will consequently not be released or revealed to any person without my express written consent or as required by law. I do, however, agree to the use of any information for research or statistical purposes so long as same does not provide facts that could lead to the identification of my person. Any other information obtained, however, will be used only by the facility staff to evaluate my exercise status or needs. 5. Inquiries and Freedom of Consent I have been given an opportunity to ask questions about the procedure. Generally, these requests, which have been noted by the testing staff, and their responses are as follows: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ I further understand that there are also other remote risks that may be associated with this procedure. Despite the fact that a complete accounting of all remote risks is not entirely possible, I am satisfied with the review of these risks, which was provided to me, and it is still my desire to proceed with the test. I acknowledge that I have read this document in its entirety or that it has been read to me if I have been unable to read same. I consent to the rendition of all services and procedures as explained herein by all facility personnel. Date ___03-10-2013___________ Bernardo Aguayo___________________________________________________________________________________ Clients Signature ___________________________________________________________________________________________________ Witness Signature ___________________________________________________________________________________________________ Test Supervisors Signature

RELEASE OF LIABILITY I_Bernardo Aguayo_, have enrolled in a program of strenuous physical activity including, but not limited to, traditional aerobics, weight training, stationary bicycling, and the use of various aerobic-conditioning machinery offered by [name of personal trainer and/or business]. I am aware that participating in these types of activities, even when completed properly, can be dangerous. I agree to follow the verbal instructions issued by the trainer. I am aware that potential risks associated with these types of activities include, but are not limited to, death, serious neck and spinal injuries that may result in complete or partial paralysis or brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system, and serious injury or impairment to other aspects of my body, general health, and well-being. Because of the dangers of participating, I recognize the importance of following the personal trainers instructions regarding proper techniques and training, as well as other organization rules. I am in good health and have provided verification from a licensed physician that I am able to undertake a general fitness-training program. I hereby consent to first aid, emergency medical care, and admission to an accredited hospital or an emergency care center when necessary for executing such care and for treatment of injuries that I may sustain while participating in a fitness-training program. I understand that I am responsible for my own medical insurance and will maintain that insurance throughout my entire period of participation with [name of personal trainer and/or business]. I will assume any additional expenses incurred that go beyond my health coverage. I will notify [name of personal trainer and/or business] of any significant injury that requires medical attention (such as emergency care, hospitalization, etc.). Signed Bernardo Aguayo_________________________________________________________ Printed Name ___Bernardo Aguayo___________ Phone Number __(208)-431-8423____ Address ____335 Harrison Street___________________________________ Emergency Contact ____Hipolito Aguayo___ Contact Phone Number ___(208)-878-7656_____ Insurance Company _____________________________________________________________ Policy # ______________________________________Effective Date _____________________ Name of Policy Holder ___________________________________________________________

Medical Release Form

Date __03-10-2013_____________

Dear Doctor: Your patient, _Bernardo Aguayo_, wishes to start a personalized training program. The activity will involve the following:

(type, frequency, duration, and intensity of activities)

If your patient is taking medications that will affect his or her exercise capacity or heart-rate response to exercise, please indicate the manner of the effect (raises, lowers, or has no effect on exercise capacity or heart-rate response): Type of medication(s) __________________________________________________________________ Effect(s) _____________________________________________________________________________ Please identify any recommendations or restrictions that are appropriate for your patient in this exercise program: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Thank you. Sincerely,

_Bernardo Aguayo____________________ has my approval to begin an exercise program with the recommendations or restriction stated above.

Signed ________Bernardo Aguayo_________________ Date ____03-10-2013_ Phone (208) 431-8423_______

Exercise History and Attitude Questionnaire

Name _____Bernardo Aguayo__________________ Date __03-10-2013 General instructions: Please fill out this form as completely as possible. If you have any questions, DO NOT GUESS; ask your trainer for assistance. 1. Please rate your exercise level on a scale of 1 to 5 (5 indicating very strenuous) for each age range through your present age: 15-20 _____ 21-30 ___X___ 31-40 _____ 41-50 ______ 51+ ______ 2. Were you a high school and/or college athlete? Yes X No If yes, please specify _________________________________________________________ 3. Do you have any negative feelings toward, or have you had bad experience with, physical-activity program? Yes X No If yes, please explain ____________________________________________________________ 4. Do you have any negative feelings toward, or have any bad experience with, fitness testing and evaluation. Yes X No If yes, please explain ____________________________________________________________ 5. Rate yourself on a scale of 1 to 5 (1 indicating the lowest value and 5 the highest). Circle the number that best applies Characterize your present athletic ability. 1 2 3 X 5 When you exercise, how important is competition? 1 2 3 X 5 Characterize your present cardiovascular capacity. 1 2 3 4 5 Characterize your present muscular capacity. 1 2 X 4 5 Characterize your present flexibility capacity. 1 2 3 X 5 6. Do you start exercise programs but then find yourself unable to stick with them? Yes X No 7. How much time are you willing to devote to an exercise program? __130___ minutes/day _____3_____ days/week 8. Are you currently involved in regular endurance (cardiovascular) exercise? Yes No If yes, specify the type of exercise(s) X ____60____ minutes/day _____4______ days/week Rate your perception of the exertion of your exercise program (circle the number): (1) Light (2) Fairly light (X) Somewhat light (4) Hard

9. How long have you been exercising regularly? _________ months __6___ years 10. What other exercise, sport, or recreational activities have you participated in? In the past 6 months?___Running, weight lifting______________________________ In the past 5 years?_____, Spinning, Insanity, cross fit, running, swimming_____________________ 11. Can you exercise during your work day? Yes No x 12. Would an exercise program interfere with your job? Yes X No 13. Would an exercise program benefit your job? No X Yes 14. What types of exercise interest you? X Walking X Jogging X Cycling X Traditional aerobics X Stationary biking X Elliptical Striding Stair climbing X Swimming X Strength training X Racquet sports X Yoga/Pilates Other activities

15. Rank your goals in undertaking exercise: What do you want exercise to do for you? Help me perform better in triathlons __________________________________________________________________________________________ Use the following scale to rate each goal separately: Not at all Somewhat important important 1 2 3 4 5 6 7 a. Improve cardiovascular fitness b. Lose weight/body fat c. Reshape or tone my body d. Improve performance for a specific sport e. Improve moods and ability to cope with stress f. Improve flexibility g. Increase strength h. Increase energy level i. Feel better j. Enjoyment k. Social interaction l. Other 16. By how much would you like to change your current weight? (+)__________lbs (-) _____5_____lbs

Extremely important 9 10

____10____ ____10_____ ____10_____ ____10_____ ____10_____ ____6____ ____9_____ ____8_____ ____8____ ____8_____ ____8_____ _________

GOALS
What are your top three long term goals? 1) ______Become a better cyclists_____________

2) _____Stay fit and run at least 2 or 3 times a week ______________________________________

3) ______See improvement in my cardiovascular endurance and maintain a healthy life style.

What are your top three short term goals? 1) _____Lose about 5 pounds and slim down around the waist_________________

2) ______Maintain a wall sit for 5 minutes____________________________

3) _________Improve my 3 mile time, running____________________________________ What are the main results that you would like to see from your personal trainer? ______Improve my 3 mile time_________________________________________________