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INTAKE FORM
FILL THIS FORM OUT WITH DETAIL AND HONESTY.
THIS WILL SERVE AS YOUR TEMPLATE FOR SUCCESS.
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Height
*
Weight
*
Age
*
Date of Birth
*
Your doctor has told you that you have a heart condition and that you should only perform physical activity recommended by a doctor.
*
Yes
No
You have a bone or joint problem that could be made worse by engaging in physical activity.
*
Yes
No
You feel pain in your chest when you perform physical activity.
*
Yes
No
Is your doctor currently prescribing you medication for blood pressure issues or a heart condition?
*
Yes
No
In the past month you have had chest pain when you were not performing any physical activity.
*
Yes
No
Can you think of any other reason not to engage in physical activity at this time?
*
Yes
No
You lose your balance because of dizziness or have you ever lost consciousness.
*
Yes
No
If you answered yes to one or more of the boxes, consult your physician before engaging in physical activity. Tell your physician which statements you answered "yes."
After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
The most important reasons why I am interested in this program are:
*
My main goals for myself are:
*
To accomplish these goals, I will have to do these three things:
*
A few possible obstacles to making these changes and how I could handle them are:
*
The most important reasons why I am improving my nutrition are:
*
To accomplish these goals, I will have to change these three eating behaviors:
*
Other people who could help me with these changes are:
*
My main nutrition goals for myself are:
*
I have had a hard time sticking to healthy eating in the past because:
*
I know my plan is working when I:
*
Submit
Home
About
>
Free Workouts
Our Team
Testimonials
UPCOMING PROGRAMS/EVENTS
Contact
Intake Form
Youth Sports Strength and Conditioning Program
On-Demand workouts and movement tutorials
NUTRITION
Class Calendar
HYROX PROGRAM
12 WEEK FITNESS PROGRAM
Blog
SIGN UP HERE!