Intake Form

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INTAKE FORM

* Indicates required field

Name *

First

Last

Date of Birth *

Phone Number *

Please allow 24 hours notice if you need to cancel or reschedule your class *

Email *

Time zone *

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

Do you feel pain in your chest when you do physical activity? *

Yes No

In the past month have you experienced chest pain when you are not engaging in physical activity? *

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

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

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 *

Do you have any injuries or medical conditions (past or present) that could affect your training? If yes please provide full details. *

What are you hoping to get out of our training? (Do you have specific goals?) *

Terms and Conditions

I have read and agree to the terms and conditions *

Yes No

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