New Client Intake

All information provided in this form will be kept strictly confidential and is submitted via a secure webpage.

This form will take between 5-15 minutes to fill out, depending on how much detail you put into the answers.  

    Name*

    Date of Birth

    Email*

    Preferred Phone to call*

    Can I text you at this number?
    YesNo

    Today’s Date

    Address

    City

    Zip

    Click on tab below to open


    STEP 1: Goals and Lifestyle

    1. What are your most important priorities today for your health and wellness?

    2. What do you LOVE to do? What activities in your life bring you the most joy? (even if you’re not doing them right now)

      3. Lifestyle Assessment

    3. How many days per week do you get physical activity? Please tell me what you do.

    4. Please rate your ability for the following on a scale of 1-10 (10 is perfect).

        12345678910 Fall asleep
        12345678910 Stay asleep/Fall back asleep if you wake up in the night
        12345678910 Manage stress
        12345678910 Positive Self-Talk (What you say to yourself in your head)
        12345678910 Digest food easily (without cramps, constipation or diarrhea)
        12345678910 Hydrate enough that your urine is pale yellow
        12345678910 Request help from your support system
        12345678910 Have enough energy to do what’s important to you

    5. What strategies do you use to manage stress?

    6. What else would you like me to know about you, your habits, your life, your world?


    STEP 2: Physical Condition

    1. Do you have any of these conditions?

      ScoliosisOsteoporosisSciaticaStenosisOther

    2. Please describe any aches, pains, numbness, tingling, or physical discomfort. Example: Low back ache, sciatica in right leg, etc.

    3. Previous Injuries

    4. Previous Surgeries

    5. For areas that you want to address now, have you received a medical diagnosis and from whom?

    6. What caused your discomfort? Include any specific event or stress-related event.

    7. What movements or situations trigger the pain?

    8. Specifically, what has helped you so far?

    STEP 3: Physical Activity Readiness Questionnaire (PAR Q)

    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 an exercise program. If you are over 69 years of age, and you are not used to being very active, check with your doctor.

    YES or NO

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

      YesNo

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

      YesNo

    • In the past month, have you had chest pain when you were not doing physical activity?*

      YesNo

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

      YesNo

    • Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

      YesNo

    • Is your doctor currently prescribing drugs for your blood pressure or heart condition?*

      YesNo

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

      YesNo

      • PAR Q: Adapted form ACSM’s Health/Fitness Facility Standards and Guidlelines, 1997 by American College of Sports Medicine

    List medications and the reasons you take them:

    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 PARQ and which questions you answered YES. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

    If you answered NO honestly to all PARQ 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.

    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. If you are or may be pregnant – talk to your doctor before you start becoming more active. Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness professional or doctor. Ask whether you should change your physical activity plan.

    STEP 4: Waiver & Policies

    Disclaimer: A fitness professional is not a medical doctor. Any chart or questionnaire does not replace the need for a medical exam and should not be used to defer seeking advice from a trained medical professional.

    Cancellation Policy: I understand that if I do not show up for my appointment, or if I cancel within 24 hours, I will be charged 100% of the fee.

    Release from Liability by Adult Regarding Participation in a Fitness Program

    This Agreement made this (date), between Joan Craig who resides at 940 River Road, Greer, SC, 29651 in Greenville County hereinafter referred to as Trainer, and (name of client), who resides at (street address, city, county, state, zip code), hereinafter referred to as “Client.”

    Whereas, Trainer is a certified Personal Trainer who primarily works with his/her clients at their home, online and at yoga studios and fitness centers; and

    Whereas, Client desires to retain Trainer to serve as his/her Personal Trainer instructing and overseeing an exercise program for Client; and

    Whereas, Trainer requires potential clients to sign a release prior to agreeing to serve as a client’s personal trainer;

    Now, therefore, for and in consideration of being allowed to participate in fitness classes and conditioning activities designed and overseen by Trainer including, but not limited to exercise, yoga, nutrition guidance, stress management, and wellness coaching, the undersigned Participant does hereby release
    Trainer from any liability which may or could occur by reason of any personal injury or property damage suffered by Client regardless of the cause or alleged cause of such personal injury or property damage.

    The undersigned Client understands that he/she will be voluntarily participating in activities which may expose him/her to some level of risk or injury, and Client represents that he/she is aware of the nature of these activities and agrees to accept any and all risks associated with participation in these activities.

    The undersigned represents that I am in good physical health, and agrees that unless I notify Trainer in writing that I am unable to participate in an activity due to some physical or mental considerations, I will be allowed to participate in all such training program. Furthermore, in consideration of Trainer allowing me to participate in these activities, I agree to hold Trainer harmless and indemnify Trainer against loss (including reasonable attorneys’ fees) from any and all claims of negligence, demands, rights, or causes of actions of any kind or nature that may hereafter at any time be made or brought by me or on my behalf for any known or unknown, foreseen or unforeseen bodily or personal injuries, damages to property and consequences thereof which may be sustained by me as a direct or indirect result of participating in the aforementioned fitness and training activities.

    CAUTION: READ BEFORE SENDING

    By checking below, I acknowledge that I understand that I am entitled to have an attorney of my own choosing to review this release prior to signing. I have read the foregoing release in its entirety and understand that I am signing a complete and perpetual release and bar to any and all claims of negligence as defined above resulting from my participation in the activities described above.

    I’ve read and accept this Terms & Conditions