1. ACE Personal Trainer Manual 5th Edition
Chapter 6: Building Rapport and the Initial Investigation Stage
Lesson 6.1

2. After completing this session, you will be able to:
LEARNING OBJECTIVES
After completing this session, you will be able to:
List and discuss the components of a successful rapport-building client interview
Demonstrate the components of the transtheoretical model of behavioral change and motivational interviewing
Assess clients’ readiness to change, utilizing motivational interviewing
Understand the purpose and process of health-risk appraisal, including ACSM risk factor stratification
Utilize the different types of evaluation forms used by personal trainers
Identify health conditions that affect physical activity (cardiovascular, respiratory, musculoskeletal, metabolic, and others)

3. BUILDING RAPPORT DURING THE CLIENT INTERVIEW
Additional attributes to a successful client–trainer relationship:
Empathy – experiencing another person’s world as if it were one’s own
Warmth – unconditional positive regard for another person
Genuineness – authenticity, or the ability to be honest and open
Trainers must also distinguish between verbal messages that reflect cognitive and affective content of the communication:
Cognitive messages are more factual
Affective messages are composed of feelings, emotions, and behaviors
Rapport is the development of a professional or personal relationship with mutual respect and understanding.

4. BUILDING RAPPORT DURING THE CLIENT INTERVIEW
Listening effectively is the primary nonverbal communication skill and occurs at different levels:
Indifferent listening: A person is not really listening and is tuned out
Selective listening: A person listens only to key words
Passive listening: A person gives the impression of listening by using minimal noncommittal agreements (e.g., head nods or “uh huhs”)
Active listening: A person shows empathy and listens as if he or she is in the speaker’s shoes

5. INTERVIEWING TECHNIQUES
It is important to use a variety of interviewing techniques to understand a client’s message, such as:
Probing: Asking additional questions in an attempt to gather more information
Clarifying: Verifying an understanding of the content of the client’s communication
Informing: Expanding upon shared information with facts
Questioning: Directing both open-ended and closed-ended questions to a client
Ultimately, try to avoid questions that simply require a “yes” or “no” answer.
Additional techniques:
Minimal encouragers: Brief words or phrases that encourage the client
to share additional information
Paraphrasing: Responding to the client’s communication by restating the
essence of the content of his or her communication Reflecting: Restating the feelings and/or content of what the speaker conveys,
but with different words. This verifies information and displays empathy and understanding. This is different than paraphrasing in that feelings or attitudes may be included (e.g., “I hear you say you’ve been unsuccessful at losing weight, but it appears that it makes you uncomfortable to discuss your previous attempts at weight loss”).
Confronting: Using mild to strong feedback with a client. This can encourage accountability when clients display lethargy or a lack of motivation toward their workout sessions. This technique should be used with caution because the trainer’s perceptions may not be based on factual data.
Deflecting: Changing the focus of one individual onto another, usually to
devalue and diminish the content of the communication. Use of this style is ill-advised unless the trainer is intentionally attempting to be empathetic by sharing appropriate experiences.

6. INTERVIEWING TECHNIQUES
Personal trainers should also select a communication style that matches the client’s needs and personality style, and the situation:
An educating style is informational, providing relevant information in a concise manner.
A counseling style is supportive, utilizing a collaborative effort to problem-solve.
A directing style is more instructive, in that the trainer provides instructions and direction.
An educating style is judgmental and delivers information in a lecture-type format by describing what the client should do. This minimizes the chances for establishing rapport.
A counseling style is supportive, utilizing a collaborative effort to problem-solve and help the client make an informed decision. This is the most effective style and is recommended when implementing a plan and/or modifying a program design.
A directing style is more instructive, in that the trainer provides instructions and direction. This style is most effective when safety and proper form and technique are essential.

7. ASKING THE RIGHT PRE-EXERCISE INTERVIEW QUESTIONS
Finding out as much information as possible about each client’s lifestyle, habits, and physical-activity history will facilitate the program-design process.
Sample questions:
Tell me about a typical week in your life.
What types of physical activities are part of your daily routine?
Do you participate in consistent business activities, such as travel or entertaining, that extend the hours of your workday or week?
How do you spend your time away from work?
When was the last time you engaged in an outdoor activity, such as walking or bicycling? Was it a leisurely pace or a vigorous intensity?
Additional questions:
Do you participate in any regular exercise, recreational travel, or physical play?
Do you experience any pain during movement?
Do you ever experience pain while exercising? If so, where and how long has it been occurring?
How long does it take for the pain to subside?
How often do you engage in this type of physical activity? How long do you spend doing it?

8. FACILITATING CHANGE AND MOTIVATIONAL INTERVIEWING
Once a trainer has developed a foundation of rapport, the next step is identifying the client’s readiness to change behavior and stage of change.
Motivational interviewing helps:
Determine the client’s level of readiness, or current stage of change
The client learn more about the reasons for change
The client participate in the behavioral change process
Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. In other words, it is an interviewing technique to get clients “off the fence” about exercise. Motivational interviewing is not about simply questioning; it involves careful listening and strategic questioning.

9. READINESS TO CHANGE QUESTIONNAIRE

10. THE HEALTH-RISK APPRAISAL
While moderate levels of physical activity promote numerous benefits, there is an increased risk for those individuals who are:
Unhealthy
Have an existing disease
At risk for disease
Pre-participation screening includes identifying:
The presence or absence of known disease
Signs or symptoms suggestive of disease
Medical contraindications
At-risk individuals who should first undergo medical evaluation
Those with medical conditions who should participate in medically supervised programs
Disease refers to cardiovascular, pulmonary, and/or metabolic disease.
Further consideration should be given when assessing an individual’s risk as to whether the exercise program is self-directed or being conducted under the consultation and supervision of a qualified fitness professional. With self-directed exercise, a standard questionnaire is completed by the individual with little to no feedback from the fitness professional. These questionnaires are designed to provide information regarding existing risks for participation in activity and the need for medical clearance beforehand. A pre-participation screening must be performed on all new participants, regardless of age, upon entering a facility that offers exercise equipment or services. The screening procedure should be valid, simple, cost- and time-efficient, and appropriate for the target population. Additionally, there should be a written policy on referral procedures for at-risk individuals.

11. THE HEALTH-RISK APPRAISAL
The Physical Activity Readiness Questionnaire (PAR-Q) is a minimal, safe pre-exercise screening measure for low-to-moderate training:
A minimal health-risk appraisal prerequisite
Quick, easy, and non-invasive to administer
Limited by its lack of detail and may overlook important health conditions, medications, and past injuries
The process for health-risk appraisal:
Review the client’s health information, medical history, and lifestyle habits
Risk stratification
Need for medical examination/clearance or supervision
Recommendations for lifestyle modification
Strategies for exercise testing and programming

12. RISK STRATIFICATION
Risk-stratification determines the presence or absence of:
Known cardiovascular, pulmonary, and/or metabolic disease
Cardiovascular risk factors
Signs or symptoms suggestive of cardiovascular, pulmonary, and/or metabolic disease
Risk-stratification is categorized as:
Low
Medium
High
Risk stratification is important because someone with only one positive risk factor will be treated differently than someone with several positive risk factors. Recommendations for physical activity/exercise, medical examinations or exercise testing, and medically supervised exercise are based on the number of associated risks; risk stratification is categorized as low, moderate, or high.
Signs or symptoms of medical conditions are included in risk stratification, but given the need for specialized training to make a diagnosis, and the importance of staying within the defined scope of practice of personal trainers, these signs and symptoms must only be interpreted by a qualified licensed professional within the clinical context in which they appear.
These signs and symptoms include the following (ACSM, 2014):
Pain (tightness) or discomfort (or other angina equivalent) in the chest, neck, jaw, arms, or other areas that may result from ischemia
Shortness of breath or difficulty breathing at rest or with mild exertion (dyspnea)
Orthopnea (dyspnea in a reclined position) or paroxysmal nocturnal dyspnea (onset is usually two to five hours after the beginning of sleep)
Ankle edema
Palpitations or tachycardia
Intermittent claudication (pain sensations or cramping in the lower extremities associated with inadequate blood supply)
Known heart murmur
Unusual fatigue or difficulty breathing with usual activities
Dizziness or syncope, most commonly caused by reduced perfusion to the brain

13. ACSM RISK-FACTOR STRATIFICATION

14. RISK STRATIFICATION EXAMPLE
Joe is a 49-year-old male who stands 5’11” (1.8 m) and weighs 240 pounds (109 kg). He currently smokes one pack of cigarettes a day and indicates no history of regular physical activity over the past 10 years. He also has a sedentary occupation and travels frequently for work. His latest physical examination revealed the following information:
Blood pressure (repeated twice): 136/88 mm/Hg
Total cholesterol 208 mg/dL; HDL cholesterol: 41 mg/dL; low-density lipoprotein (LDL) cholesterol: 134 mg/dL
No medications
Fasting blood glucose (last medical exam): 98 mg/dL
Family history:
Father diagnosed with CAD at age 62
Mother diagnosed with type 2 diabetes at age 50
What are his positive risk factors for heart disease?
Answer: Age, current smoker, high LDL, high BMI, and sedentary lifestyle
What is his risk stratification according to the ACSM Guidelines?
Answer: Moderate, as he has no known diagnosis, although he has five positive risk factors
What testing and programming guidelines should a personal trainer follow prior to working with Joe?
Answer: Theoretically, he could participate in moderate-intensity activity and submaximal testing without a medical exam. However, given his number of risk factors, Joe should consider getting a medical exam before starting an exercise program.

15. EVALUATION FORMS Informed consent: Agreement and release of liability:
The client acknowledges having been informed about the risks associated with activity
Discloses the purposes, procedures, risks, and benefits associated with the assessments
Agreement and release of liability:
Releases a personal trainer from liability for injuries resulting from a supervised exercise program
Represents a client’s voluntary abandonment of the right to file suit
Does not necessarily protect the trainer from being sued for negligence
It is recommended that personal trainers consult a legal professional familiar with local and regional laws prior to utilizing the informed consent and agreement and release of liability forms.
Visit to download a free PDF of a health-history questionnaire, exercise history and attitude questionnaire, and medical release form, as well as other forms and tools that you can use throughout your career as a personal trainer.

16. Health-history questionnaire:
EVALUATION FORMS
Health-history questionnaire:
Past and present exercise and physical-activity information
Medications and supplements
Recent or current illnesses or injuries, and chronic or acute pain
Surgery and injury history
Family medical history
Lifestyle information (related to nutrition, stress, work, sleep, etc.)
It is recommended that personal trainers consult a legal professional familiar with local and regional laws prior to utilizing the informed consent and agreement and release of liability forms.
Visit to download a free PDF of a health-history questionnaire, exercise history and attitude questionnaire, and medical release form, as well as other forms and tools that you can use throughout your career as a personal trainer.

17. EVALUATION FORMS Exercise history and attitude questionnaire:
The client’s previous exercise history and behavioral and adherence experience
Medical release:
The client’s medical information
Explains physical-activity limitations and/or guidelines as outlined by the physician
Deviation from these guidelines must be approved by the physician
Testing forms:
Used for recording testing and measurement data during the fitness assessment
It is recommended that personal trainers consult a legal professional familiar with local and regional laws prior to utilizing the informed consent and agreement and release of liability forms.
Visit to download a free PDF of a health-history questionnaire, exercise history and attitude questionnaire, and medical release form, as well as other forms and tools that you can use throughout your career as a personal trainer.

18. HEALTH CONDITIONS THAT AFFECT PHYSICAL ACTIVITY
Injuries related to physical activity usually come from:
Aggravating an existing condition (either known or unknown by the client)
Precipitating a new condition
The cardiovascular, respiratory, and musculoskeletal systems all experience stress during physical activity.

19. CARDIOVASCULAR DISEASE
Atherosclerosis:
Accumulation of fatty cholesterol and calcium deposits on artery walls causing hardening, thickening, and loss of elasticity
When this process affects the arteries that supply the heart, it is called coronary artery disease (CAD).
Myocardial infarction or heart attack:
May result from atherosclerosis when the blood supply is limited and the increased oxygen demand cannot be met
Angina:
May also result from atherosclerosis
Described as pressure or tightness in the chest, arm, shoulder, or jaw
May be accompanied by shortness of breath, sweating, nausea, and palpitations
Coronary artery disease:
A history of CAD or chest pain should have a physician’s release
Many people with CAD have no known symptoms.
Hypertension:
Prevalent among elderly and African-American individuals
The risk of CAD, stroke, and kidney disease increases with higher levels of systolic and diastolic blood pressure.

20. RESPIRATORY SYSTEM DISORDERS
Respiratory system disorders will interfere with the body’s ability to provide enough oxygen for the increasing demand that occurs during aerobic exercise:
Bronchitis
Asthma
Chronic obstructive pulmonary disease (COPD)
Any client with a respiratory disorder should have physician’s clearance:
These conditions may result in dyspnea.
Regular exercise may aggravate the condition for some people.
Conversely, exercise may improve it.

21. MUSCULOSKELETAL DISORDERS
Clients should be referred to an appropriate healthcare professional and have a physician’s clearance to exercise if they suffer from issues such as:
Minor sprains and/or strains
Runner’s knee/swimmer’s shoulder/tennis elbow
Iliotibial band syndrome (ITBS) or shin splints
Spine disorders, such as herniated discs
Bursitis
Tendinitis
Arthritis
Significant muscle weakness or joint laxity
Recent orthopedic surgery, and any disuse atrophy
The musculoskeletal system consists of the muscles, bones, tendons, and ligaments that support and move the body. This is the system most commonly injured during exercise. Aside from the pain and discouragement of an injury, there are other factors with which to contend. Client motivation and the trainer’s scope of practice create concerns when working with a client with previous or current musculoskeletal injuries. Changes or modifications in the exercise program are necessary to accommodate the injury. For these reasons, it is important to be cognizant of potentially hazardous situations before they occur.

22. METABOLIC DISORDERS Diabetes: Thyroid disorders:
A client’s situation and exercise program should be discussed with his or her physician before working with a personal trainer.
Requires physician approval before starting an exercise program, especially if receiving insulin
Thyroid disorders:
Hyperthyroid individuals have an increased level of thyroid hormones and a higher metabolic rate.
Those with hypothyroidism have a reduced level of hormones and require thyroid medication to regulate their metabolism.
Require physician approval before starting an exercise program

23. OTHER CONDITIONS Hernia: Pregnancy: Illness or infection:
A protrusion of the abdominal contents into the groin or through the abdominal wall
May be further aggravated by the Valsalva maneuver
Is a relative contraindication for resistance training unless cleared by a physician
Pregnancy:
Important to maintain a good fitness level, instead of maximum fitness goals
A client should have physician’s approval until three months after delivery.
Illness or infection:
A recent history may impair a client’s ability to exercise.
Moderate exercise may be appropriate during a mild illness.
Generally not advisable to start a new exercise program during an illness

24. SUMMARY
Personal training is about behavioral change, which is the true measure of a successful client–trainer relationship.
Perhaps the most crucial factor for determining a positive climate for the working relationship is the trainer’s repertoire of communication skills.
By determining the client’s needs and desires, personal trainers can appropriately respond at various stages of the client’s readiness to change.
It is important to conduct a thorough health-risk assessment utilizing appropriate health-risk appraisals and risk stratifications.