Intake Form

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Intake Form

* Indicates required field

Name *

First

Last

Date of Birth *

Phone Number (including area code) *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Time zone *

Please enter your country and timezone

Emergency Contact *

First

Last

Emergency Phone Number (including area code) *

Par-Q

Has your doctor ever said you have a heart condition, and that you should only do physical activity recommended by a doctor? *

Yes No

In the past month have you experienced chest pain in your chest? *

Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes No

Do you have a bone, joint or any other health problem that causes you pain or limitations, that MUST be addressed before we commence training together? *

Yes No

Are you pregnant now or have given birth within the last six months? *

Yes No

Have you had a recent surgery? *

Yes No

Do you know of any other reason why you should not do physical activity? *

Yes No

If you have answered Yes to any of the above questions, please provide detailed information. If No, please write NA. *

Do you have any injuries or medical conditions (past or present) that could affect your training? If yes please provide full details. If no, please write NA. *

How would you rate your current level of fitness? (1) I'm just getting started (5) I'm in the best shape of my life *

1 2 3 4 5

Please tell me a little about yourself? (e.g hobbies, book that changed your life, dog's name?) *

Waiver and Release

I have read the above Waiver and Release form and agree to the terms outlined within *

Yes No

Submit

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