Intake & Health History Questionnaire
First Name
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Last Name
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Date of birth
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Refunds: There will be NO refunds for nutrition or any personal training sessions. Please initial below.
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Clear
No pausing membership: Consistency and Accountability are the key to my success. My coach will help me stay consistent even when I’m traveling. I understand that I cannot pause my membership and I will lose any sessions that I cannot attend. Please initial below.
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Clear
Monthly membership: I understand that there is a 3-month commitment and that I’m billed every 4 weeks. Please initial below.
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Clear
Cancellations: I understand that the trainer operates on a scheduled appointment basis for all sessions and thus requires 12 hours’ notice when I cancel/reschedule an appointment. No charges shall be levied should I cancel/reschedule with more than 12 hours’ notice. Should I cancel within the 12-hour window, I will forfeit my session, and I will purchase an additional session if I wish to reschedule. Please initial below.
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Clear
Expiration: Sessions will expire each new billing cycle. Any unused sessions will not roll over to the next month. Please initial below.
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Clear
What are your goals? Be specific (Improved health, sport-specific, fat loss, weight gain, Increased strength, confidence etc.)
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Do you have a specific timeline for achieving your goal(s)? When?
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How did you hear about us?
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What is your current activity level? (run 3x/week, lift 2x/week, none, etc.) Be as specific as you can. How long have you been on this training program?
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What is your current eating habit? Please keep a food journal for at least 3 days, the more the better. We recommend MyFitnessPal app for food tracking.
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How well do you sleep? How many hours of restful sleep do you get on average each night?
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What is your stress level? (Rate 1 to 5, 5 being the worst) How do you manage your stress?
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On a scale of 1 to 10, how committed are you to achieving your goals? (1 - I don’t care when I reach my goals; 10 - nothing will stop me!)
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Do you currently have an injury or have you had any injuries in the last 6 months? If so, please specify.
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Did you see a medical professional about this injury? Is yes, whom?
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Are you medically cleared by your physician to start an exercise program?
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Yes
No
Not Applicable
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Past Medical History: Please check all of the following that apply to you. Explain all “Checks” and include approximate dates in the next field:
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Have you ever had surgery?
Are you currently taking any medications?
Do you have any allergies?
Have you ever been dizzy or fainted after/during exercise?
Have you ever had chest pains after/during exercise?
Have you ever had high blood pressure?
Do you have a heart murmur or other heart condition?
Have you ever had a head injury, been knocked out or unconscious?
Have you ever had a seizure?
Have you ever had a stinger, burner, or pinched nerve?
Do you ever have any trouble breathing during or after exercise?
Do you have any skin problems (rashes, itching)?
Have you had any problem with your eyes or vision?
Do you have only one working organ of usually paired organs (eye, kidney, etc)?
Have you had any other medical problems (asthma, diabetes, etc.)?
Have you ever sprained, broken, dislocated, had repeated pain or swelling of any bones or joints?
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Please explain any "Checks" from above and elaborate your health history here.
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Disclaimer: During your exercise program, every effort will be made to assure your safety. However, as with any exercise program, there are risks and illnesses (ex: communicable diseases such as MRSA, influenza, and COVID-19), including increased heart stress and the chance of musculoskeletal injuries. In volunteering for this program, you assume responsibility for these risks and waive any possibility for personal damages. You also agree that, to your knowledge, you have no limiting physical conditions or disability that would preclude you from an exercise program. If you do have any medical issues that may be of concern, you further agree that a physician has cleared you to participate in a training and nutrition program. A physician's examination is recommended for (1) all participants with any exercise restrictions; (2) all men >44 years old and all women >54 years old. Coaching participants in either or both of these categories who do not have prior physician examination MUST acknowledge they have been informed of its importance. By typing your FULL NAME below, you accept full responsibility for your own health and well being, and you acknowledge an understanding that the leaders of this program assume no responsibility.
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Submit