START HERE: NEW CLIENT INTAKE FORM Name First Name Last Name Email Phone (###) ### #### Birthday MM DD YYYY Occupation Have you ever worked with an in-person or online coach/trainer? Yes No How long have you been training (training age)? Training History: what programs (if any) have you done for the past 6 months? bodybuilding, powerlifting, sports performance, marathon, CrossFit, Hyrox, etc. What is your current training routine? Training splits, exercise selection, sets and reps, etc. Injuries related to training / caused by what movement: Non-training related injuries: Personality Type - would you say you're more type A (stress-prone and impatient) or type B (less stress-prone and patient) Type A Type B Least favorite training modalities? What gym equipment do you have access to? On a scale of 1 - 5, how would you rate your current activity level? 1 2 3 4 5 Do you have any pre-existing or current health conditions, injuries, surgeries or complications? Yes No What are your top 3 health and fitness goals? What is your daily nutritional intake like? For example, how many meals a day, typical meals, macro numbers, etc. The more details the better. What can I do to help you be successful? Questions, concerns, anything at all? How did you hear about me? Physical Activity Readiness Questionnaire (PAR-Q) 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 carefully and answer each one honestly: Has your doctor ever said that 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 had chest pain when you were not doing 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 or joint problem that could be made worse by a change in your physical activity? Yes No Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? Yes No Do you know of any other reason why you should not do physical activity? Yes No If you answered YES to one or more questions, Talk to 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 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. 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. Thank you for taking the time to fill out the form, meanwhile feel free to go through some of these free resources and we will be in touch soon!
