There is no better way to start than by learning how to perform client screening, and knowing what questions should be asked during the first client consultation appointment (refer to Consultation Guidelines). You should always suggest that your client see his or her personal physician prior to starting or increasing the intensity of his or her existing exercise program, even if the client is not at risk for health reasons. Inform the prospective client up front that the answers to any and all questions during client screening are strictly confidential. Emphasize to the client the importance in answering all questions as specifically and honestly as possible. This will allow you to provide them with the most effective recommendations possible. For client safety, and for professional and liability reasons, you should always maintain current CPR Certification. It is always possible, even though you will only be training apparently healthy individuals, that there will be a need for the performance of CPR. As a qualified and conscientious personal fitness trainer, it would be both professional and appropriate to maintain CPR Certification.

Major Risk Factor Identification
The most valuable service you can offer your client is the identification of his/her specific "health risk factors". Your NFPT Certification will not qualify you to administer exercise to persons with one or more Major Health Risk Factor(s) present without the direct involvement of a medical physician (approval). The following are Major Risk Factors that need to be identified. These questions must be asked while filling out the consultation questionnaire:
1) Do you have diabetes?
2) Is the client clinically obese (body composition interfering with the performance of the simplest of daily tasks)?
3) Is your TOTAL cholesterol to HDL cholesterol ratio greater than 5 to 1?
4) Have you ever had an abnormal exercise ECG?
5) Do you have a history of high blood pressure?
6) Do you have a family history of coronary or other atherosclerotic disease prior to age 50?

Once again, as a reminder, your NFPT Certification will not qualify you to administer exercise to persons with one or more Major Health Risk Factor(s) present without the approval of a medical physician.

Personal Medical History
There are several other questions that must also be asked in reference to obtaining more specific medical background information:

Have you ever suffered:
heart attack
had bypass surgery
cardiac surgery
extreme chest discomfort
high blood pressure over 145/95
over 35 and smoke
serum cholesterol over 240 mg/dcl
irregular heart beats
heart murmurs
rheumatic fever
ankle swelling
any vascular disease
phlebitis
unusual shortness of breath
fainting
asthma, emphysema, or bronchitis
abnormal blood fat levels
stroke
emotional disorders
recent illness, or hospitalization
drug allergies
orthopedic problems, or arthritis

If your prospective client answers yes to any of these questions, you cannot train him/her without a complete physical, or the approval of their personal physician.

Family History of Illness or Disease
Ask if your client has ever had an immediate family member die prior to the age of 50, and the cause of death. With the exception of accidental death, parental and sibling illnesses and diseases, especially cardiorespiratory diseases and bloodsugar abnormalities, are often times inherited. Inform the client of his/her increased susceptibility to these specific disorders and recommend relative lifestyle changes that will help offset the likelihood of your client suffering these family specific disorders. The lifestyle changes to be recommended are discussed in detail elsewhere in this text.

Cardiovascular Risk Profile
The next step is the completion of a "Cardiovascular Risk Profile Questionnaire". Your sample questionnaire is relatively self-explanatory and very objective. A client score of over 32 on this questionnaire would likewise be reason enough not to train this individual prior to the performance of a complete physical and/or the client's physician's approval.

Current Client Medication
If the client is on prescription medication, require that the client contact his/her physician or qualified pharmacist to insure there are no risks involved in starting the exercise program while on this medication.

Chronic Illness, Injury or Limitations
If the client is currently ill, put off starting his/her exercise program until they are over the illness. If the client suffers from a chronic, or recurring illness, care should be taken that the illness is not complicated by exercise. If a client has a chronic injury or a range-of-motion limitation, it should always be advised that he/she see their personal physician, a licensed physical therapist, or an orthopedic physician prior to implementing your recommendations. In the case of range-of-motion limitations, this therapeutic referral need be made only if recommendations involve the articulation (movement) of the injured site(s). You must also avoid recommending movements that aggravate above conditions. Inform the client to stop exercising if he or she experiences relative symptoms or undue pain of any kind, and consult immediately with you, and if need be, with his/her physician.

Contraindications to Exercise
As a personal fitness trainer, you must inform your client of the contraindications (symptoms of overexertion or injury) to exercise, so the client will be able to distinguish the difference between discomfort that is to be expected, and discomfort that could indicate an underlying problem. If a client experiences any joint pain, dizziness, nausea, rapid pulse, excessive sweating, extreme muscle soreness, cramping, or chest pain, he/she should immediately stop exercising, consult with you, and if need be, their personal physician. Contraindications to exercise will be discussed ater in this text as well.

Summary of Physician Assistance
A physician must be directly involved if a Major Risk Factor is present. A physician's consent and/or a complete physical must be obtained when #1) adverse personal medical history symptoms warrant; #2) the client's cardiovascular risk profile score is over 32; #3) there is a significant and restrictive chronic illness or range-of-motion limitation; or #4) contraindica-tions persist.

As initially stated, all clients, even apparently healthy individuals, should be advised up front to visit with a physician prior to starting or increasing the intensity of his or her existing exercise program. You are not however, obligated to require the apparently healthy client to do so.

General Client Information
This may sound a bit cliché, but a quality personal fitness trainer will evaluate a client's total lifestyle not just their exercise needs. There is more to health than just exercise alone. The following is a brief overview of each of the General Client Information topics included in your NFPT Client Screening Questionnaire.

Age - Knowledge of client age is useful in determining health risks, exercise intensity and duration, as well as for computing maximum heart rate (220 - age).

Sleeping Habits - Poor sleeping habits can reduce recovery effectiveness, lower Growth Hormone release, and can cause mental fatigue and inability to concentrate. Sleep is the body's built-in recovery mechanism. A protein builds up in the cerebrospinal fluid during waking hours that can be broken down only during sleep. Moreover, sleeping abnormalities can usually be directly linked to stress and improper diet.

Water Intake - Persons taking in too little fluids are more susceptible to dehydration during exercise. Prolonged low fluid intake can lead to a survival water retention in the body. Refer elsewhere in this text for more information on water ingestion.

Sex - This information is usually needed for demographic reasons. Gender also is a consideration in determining health risks as is indicated on the Cardiovascular Risk Profile Questionnaire.

Weight - Weight is generally a determining factor in first establishing your client's goals. Body composition measurement first requires measurement of total weight. Knowledge of weight is also of obvious re-evaluation benefit in consulting clients. Don't simply ask the client their weight, accurately weigh the client yourself using the guidelines provided in the Diagnostic Testing segment of the Client Screening Questionnaire later in this chapter.

Height - This information is usually needed for demographic reasons. Also, height is a determining factor in setting client goals based on national height & weight standards. These standards have been established by major health insurance companies, as a very general indicator of physical condition.

Occupation - Knowing what type of daily activities your client performs will assist you in determining total caloric intake, meal timing, exercise scheduling, and possible lifestyle change recommendations. Occupational stress may also be a consideration.

Most Recent Exercise Program
In order for you to optimize the results of your client's new resistance exercise program, you must learn as much as possible about their past resistance exercise program. Question your client concerning past resistance exercise, if any, paying special attention to the following questions and the appropriate responses:

Type of routine - The client should have used a circuit routine for fat loss and aerobic conditioning vs. a split routine for lean weight gain.

Total sets per muscle group - The larger the target muscle group, the more total sets used.

Typical number of reps per set - Fewer reps for lean weight increase, and more reps for fat reduction and aerobic conditioning.

Recovery between sets & workouts - Longer recovery for lean weight increase, and shorter recovery for fat reduction and aerobic conditioning.

Movements used - Always use compound movements for both lean weight increase as well as fat reduction and aerobic conditioning.

Length of workouts - Short high intensity workouts should be performed for lean weight increase, and long low intensity workouts should be performed for fat reduction and aerobic conditioning.

Time of daily exercise - Train later in the day for lean weight increase, and early in the day for fat reduction and aerobic conditioning.

Even if your client does not have any prior resistance experience at all, you will still need to know what type of past exercises have been performed, if any, in helping you to recommend their starting exercise intensity and duration. This topic is discussed in greater detail elsewhere in this text.

Has Client Been Advised Against Exercise
If the client has ever been instructed by a physician not to exercise for any reason not already covered in the Client Screening Questionnaire, you need to know.

Stress - As a personal fitness trainer, you can still determine, to some extent, the degree of stress your client is under. While questioning the client, solicit answers to questions such as..."Do you feel you are under a lot of stress at work? Are you easily upset? Would you say you are always trying to do two or three things at once? Do you enjoy an active social life?" Answers to these types of questions along with the answers to occupational, sleeping habits, and later covered dietary questions, may point towards a need for special attention. Make arrangements for referrals to a stress management professional. On a smaller scale, stress can sometimes be effectively controlled through proper dietary consideration, increased physical activity, improved sleeping habits, etc., therefore contributing to an all around healthier lifestyle.

Long & Short-Term Goals - The client's long and short-term goals are invaluable. In order for you to effectively implement the NFPT Charts and Tables. There can be no confusion concerning client goals.

Client Eating Habits - Ask the client to give you as detailed a list as possible of his/her typical daily food selection, number of meals, meal timing, size of meals, hunger between meals, and current supplements being taken. The significance of these dietary concerns will be more clear after familiarizing yourself with the chapter on Diet & The Metabolism of Nutrients. This list of questions can be found in your NFPT Guidelines. The answers to these questions will be extremely helpful in your using the NFPT Dietary Advise Chart. Also, give the client a copy of your Master Food List, located in the rear of this manual. This will assist the client in implementing your recommendations.

Controllable Dietary Health Risk Habits Provided in your guidelines is a list of Dietary Health Risk Habits. This list outlines the ill effects of specific health risk foods for your review and use in educating clients to make healthier food selection in the future.

Acquiring Informed Consent - Now that your client has been screened, he/she must give you informed consent prior to the performance of pre-exercise tests and/or the administration of the exercise program itself. Of relative importance, insure that the client understands the contraindications to exercise, as earlier listed, and is allowed to question you concerning the possibility of injuries that may occur with resistance training. Then, prior to requiring physical activity, use the optional "Informed Consent" waiver included in your NFPT Guidelines. Also, you have been provided with the "Par-Q & You" Form. This form is used internationally as a client waiver prior to the performance of "pre-exercise" tests of all kinds. It is strongly suggested, and is in your best interest, to use this form as well.

Optional Diagnostic Tests to Perform Dependent on Acquired Skills. Consider acquiring appropriate diagnostic skills enabling you to perform tests lending to the efficiency and professionalism of your personal fitness trainer services. The ability to competently perform diagnostic tests will make your services more marketable, more unique, more effective, and attractive to prospective clients/members. The following is a list and explanations of the various types of diagnostic testing you can perform with a minimal amount of education and required skills. For clarification on requirements involved in offering the below services, contact the appropriate health professionals in your area.

Measurement of Client Weight - Total body weight must be accurately determined for client goal setting, lean body weight measurement, and overall client progress evaluation. Client weight can most accurately be determined through the use of a well calibrated "hospital" scale. Take written notes of the time of day, and clothing worn by the client at weigh-in. This is for accuracy in future re-evaluations to be discussed later.

Circumference Measurements - Accurate circumference measurements are extremely valuable regardless of your clients' goals. Circumference measurements will be altered regardless of the type of resistance activity and relative desired adaptation. Take measurements at the following anatomical sites regardless of client sex:
Neck, chest, upper arms, waist, hips, forearms, thighs, and calves.
The specific location at these anatomical sites should be chosen in such a manner as to be positioned near landmarks such as a mole or some other easily distinguishable skin imperfection, for the sake of future re-evaluation consistency. Some personal fitness trainers actually stain test sites with ink to create temporary landmarks.

Body Composition Measurement - The measurement of body composition (body fat vs. lean muscle) requires #1) the prior knowledge of total bodyweight, and #2) the proficient use of skin fold calipers, either manual or electronic. There are other various types of body composition testing equipment available, unfortunately at much greater expense. The purchase of a body composition testing device of any kind is an excellent investment. If you are in need of such a device, contact NFPT Headquarters for purchasing information.

For various device use and anatomical site(s) selection, refer to specific operations manuals accompanying the purchased device. For re-evaluation purposes, this will be the most valuable diagnostic tool you have. For this reason, the enrollment of this tool will be discussed in greater detail elsewhere in this text.

Blood Sugar Analysis - The 12-hour fasted use of "Glucostix" or a "Glucometer" will effectively reveal to you any abnormality in blood sugar. The average adult's normal 12-hour fasted blood sugar ranges from 70-110 mg/dcl. A lower reading may indicate Hypoglycemia where a higher reading may indicate a Diabetic problem. Pre- and post-exercise blood sugar monitoring may also prove valuable in adjusting dietary intake around training. The NFPT recommends that these tests be performed by the appropriate health professionals to assure the use of universal precautions in the handling and disposal of blood products or body fluids.

Ketone Testing - Initial client Ketone testing is usually unnecessary in the apparently healthy individual. It is during periods of starvation dieting and/or extreme overexertion that this test should be applied on a re-evaluation basis. This test is discussed later in this chapter. Blood Pressure Testing - Your ability to offer blood pressure screening has skill requirements especially if you intend to perform submaximal pre-exercise testing. This testing calls for the client to perform aerobic activity usually in the form of ergometer cycling. At three (3) separate stages, blood pressure measurements are taken. Ideally, the Systolic (above) reading should rise slightly while the Diastolic (below) reading should not change dramatically. If either results are not the case, the client should gradually slow to a stop, and a physician notified for the scheduling of a medically supervised "maximal" pre-exercise test. With the influx of hypertensive persons needing to monitor blood pressures away from the doctor's office, the medical supply industry now provides battery operated, digital display, blood pressure testing kits for self-testing. These kits can easily be applied by the personal fitness trainer in taking supine, seated, and standing blood pressure readings as he/she sees fit. Without proper certification or training in blood pressure screening, you are not qualified however, to perform submaximal pre-exercise testing. Should you be interested in performing submaximal exercise testing, this certification is not a complicated process. While attending class, ask detailed questions concerning submaximal exercise testing procedures.

Muscle Strength Test - A muscle strength test will be useful for determining initial strength/lean tissue of the fat loss client, and for determining initial strength/lean tissue of the weight gain client. In either case, select a weight to be used in the bench press movement that will allow for client performance of between 4 to 6 repetitions in strict form to concentric (positive) failure without the need of assistance. Keep record of the weight and reps performed for future re-evaluation. It may be desirable in the case of the resistance trainee beginner, to incorporate the use of a machine for this test as poor balance and form using free weights may put the client at risk of injury. The strength test is easily applied and extremely useful in continued lean weight monitoring in all client situations. Compiling Recommendations - This should conclude your Client Screening Questionnaire. Take a few days to compile your recommendations using the provided charts and tables in accordance with the NFPT Guidelines. For more complete information on applying NFPT Charts & Tables, refer to the following chapter.

Periodic Re-Evaluation - On predetermined dates, the appropriate diagnostic tests should be repeated for the purpose of result comparisons, and consequent client progress. Weight Measurement - A client's weight change is too often considered one of the most valuable factors in determining the success or failure of a fitness program. The enrollment of resistance exercise in weight management brings with it changes in body composition that need to be discussed briefly here and in greater depth later.

Since fat (light) is lost, and muscle energy stores (heavy) increase through weight training, total weight could possibly increase temporarily. This may occur even while weight loss is the goal. Therefore, being able to calculate the changes in fat weight separate from the changes in muscle weight is the real indicator of a fitness program's success. Use the same methods of weight measurements outlined earlier for the greatest degree of accuracy. Circumference Measurement - Clients desiring lean weight increase may or may not initially show significantly increased circumference. The possible loss of fat tissue in the areas of measurement may even reflect a reduction in circumference depending upon the current diet and exercise program used. If circumference does not enlarge in the client desiring size increase for an initial temporary period, the measured reduction in bodyfat and increased strength will have to be used as the indicators of progress. As for the client wishing to lose weight, circumference should begin to decrease within the first month of adherence to the appropriate NFPT Guidelines concerning fat loss diet & exercise principles.

Body Composition Measurement - Without question, this is the most valuable re-evaluation tool at the personal fitness trainer's disposal. Regardless of the device used to determine bodyfat percentage, the resulting information is the same. Take the client's total weight and multiply this figure times the calculated percentage of bodyfat, and you will have arrived at the client's total fat weight (Weight x BF% = Fat Weight). Subtract the resulting fat weight from the total weight and you will have arrived at the client's lean weight (Weight - Fat Weight = Lean Weight). If your client's goal is weight loss, you should attempt to maintain or even increase this Lean Weight figure while reducing Fat Weight through implementing diet and training changes discussed later in this text. If your client's goal is to increase size and strength, you should obviously attempt to improve upon this Lean Weight figure while minimizing or disallowing any increase in Fat Weight. Lean weight considerations are made throughout this text in great detail. Ketone Testing - When a client is on a fat loss diet and chooses to lose weight at a more rapid rate than is safe by NFPT standards, your necessary and logical course of action would be to safeguard the client's health. During starvation dieting, muscle is rapidly lost along with fat leading to long-term metabolic problems. The use of Keto-Stix will indicate when too much body tissue (muscle) is being cannibalized for energy which can lead to metabolic acidosis, coma, and death. Evaluate Ketone levels on frequent dates during unsafe dieting practices. This is a self-test with label directions, and qualifications are not required of the user. Keto-Stix are marketed as a self-test for individuals with bloodsugar abnormalities (usually Diabetes & Hypoglycemia). Monitoring tissue loss is a valuable modified enrollment of this product.

Blood Pressure Testing - It has been shown that regular resistance exercise will lower blood pressure during lifting activities in comparison to lifting activities of the same absolute weight prior to training. In other words, Joe initially lifts 100 pounds which is 80% of his one repetition maximum. After several weeks of resistance training, Joe improves his strength such that 100 pounds is now only 70% of his one repetition maximum. By monitoring blood pressure during his initial training and comparing it to that during current training, you will see a favorable decrease in both Systolic and Diastolic pressures because lifting 100 pounds is now easier. This training effect may carry over to other activities and therefore reduce overall resting blood pressure. This further supports the use of resistance exercise with your clients to help reduce their blood pressure during activities of daily living. Refer back to Optional Diagnostic Tests for information on imposed limitations concerning blood pressure screening.

Muscle Strength Tests - Periodic Muscle Strength Tests will effectively monitor the associated loss/maintenance of strength/lean tissue in the weight loss client. Periodic tests will also effectively monitor the associated maintenance/ gain in strength/lean tissue associated with the weight gain client. It is always ideal to improve upon the volume of lean weight whenever possible. Metabolism increases with lean weight volume increase. Lean weight loss is frequently indicated when strength levels drop. This is obviously undesirable and must be corrected through dietary and training changes discussed later.

Re-Examine Client Goals - Dependent upon client progress, desired goals may change. If this is the case, you will need to once again refer to the NFPT Charts & Tables to make the necessary altered recommendations.