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 10-20 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

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  • STEP 1: Goals and Objectives
  • STEP 2: Lifestyle Assessment
  • STEP 3: Physical Condition
  • STEP 4: Physical Activity Readiness Questionnaire (PAR Q)
  • STEP 5: Waiver & Policies

  1. Please tell me what you want to do but cannot or do not do right now, and how you want to feel. What is the most important change you'd like to see in your life?
  2. What’s getting in your way? (What obstacles do you face?)
  3. 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)

  1. How many servings of fruits and vegetables do you eat most days?

    (Serving size is 1/2 cup so the size of your fist is about 2 servings.)

  2. How many ounces or glasses of water do you drink on most days?
  3. What time do you normally go to sleep?
  4. What time do you normally wake up?
  5. Please rate your ability for the following on a scale of 1-10 (10 is perfect).
      Fall asleep
      Stay asleep/Fall back asleep if you wake up in the night
      Manage stress
      Positive Self-Talk (What you say to yourself in your head)
      Digest food easily (without cramps, constipation or diarrhea)
      Have enough energy to do what matters
  6. What strategies do you use to manage stress?
  7. How many days per week do you get physical activity? Please tell me what you do.
  8. Please list the people who support you the most and want you to be your best.
  9. What else would you like me to know about you, your habits, your life, your world?

  1. Previous Surgeries
  2. If there is a single most important physical issue to address, what is it and what caused it? Include specific event or stress.
  3. How long have you had the problem?
  4. List all medications and vitamins/supplements and the reason you take them.
  5. Please describe any other health issues that you want me to know about.

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 Guidleines, 1997 by American College of Sports Medicine


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.

By accepting this document, I acknowledge that I have been informed of the need to obtain a physician’s examination and approval prior to beginning this wellness, nutrition, and exercise program. I fully understand that the program may be strenuous and choose to participate completely voluntarily. I accept all responsibility for my health and any resultant injury or mishap that may affect my wellbeing, or health in any way. I hold harmless of any responsibility, the instructor, facility or any persons involved with this program or testing procedures.

I understand that 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.

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.

I’ve read and accept this Terms & Conditions