TDAE Intake Form

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Scheduling: Next Steps

Upon completing this form you will be redirected to our scheduling page where you can schedule one of the following:

- 15 Minute Call

- 30 Minute Virtual Assessment

- 60 Minute In-Person Assessment
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Are you coming in for Physical Therapy or Custom Coaching?* This field is required.
Custom Coaching (Personalized training, in-person coaching & instruction, and in the gym)
Online Training (Personalized virtual training program)
Golf Strength Program
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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Picture of YourselfThis will ONLY be used as a profile picture in our client management system. This is completely optional, so no pressure to include a photo!
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Mobile Number* This field is required.
Area Code
Phone Number
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Can you receive text messages at the number you included?* This field is required.
YESNO
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Date of Birth* This field is required.
Date
Month
Day
Year
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Age: * This field is required.
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Gender: * This field is required.
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Height: * This field is required.
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Weight: * This field is required.
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Emergency Contact Full Name:
If you are training with us in-person
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Relationship to Emergency Contacted Listed:
If you are training with us in-person
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Emergency contact phone number:
Area Code
Phone Number
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What do you currently do for work? * This field is required.
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How did you hear about us?* This field is required.
TDAE Website
Facebook/Instagram
Drove By
Recommended by a friend or colleague
Other
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What is the name of the individual who referred you to TDAE?
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Are you currently taking any medications that would stop you from doing sport or exercise?* This field is required.
List the medication(s) if YES
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Do you have any preexisting cardiovascular condition that would stop you from sport or exercise?* This field is required.
Describe the condition if YES
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List any medical conditions that would impact your response to exercise or that we should be aware of:* This field is required.
Examples: Pregnancy, auto-immune disease, neuromuscular conditions
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List and describe all current or prior injuries, surgeries or areas of nagging discomfort:* This field is required.
List with dates and indicate right vs. left side. Be specific :)
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Identify any injuries or areas of nagging discomfort from the list above that are current or actively limiting you:* This field is required.
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List any specific exercises, movements, or general activities that you have eliminated or stopped doing due to pain:* This field is required.
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List any specific exercises or movements that you simply do NOT like to do: * This field is required.
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List any specific exercises or movements that you just LOVE to do: * This field is required.
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Do you currently participate in a formal resistance training routine on a consistent basis? If so, at what frequency? * This field is required.
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How many days per week do you currently perform other modes of activity or exercise (run, swim, spin, yoga, etc.)? * This field is required.
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List any fitness based events you are preparing for or any competitive sports that you currently play. * This field is required.
List the event names and dates. If playing multiple competitive sports, list in priority.
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Describe the goals that we can help you to work towards:* This field is required.
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Are you interested in a certain type of membership?Not sure? Don't worry, we are happy to discuss the options during your assessment.
Online Only
Hybrid (Combination of home and in-person workouts at TDAE)
I am not sure yet and would like to discuss the options
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Do you have an idea or goal of how many days you would like to train per week?* This field is required.Not sure? Don't worry, we are happy to discuss this during your assessment.
1x/week
2x/week
3x/week
4x/week
I am not sure and would like guidance and recommendations from TDAE
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What type of equipment do you currently have access to?When writing a program for a home environment or gym closer to you, we need to know what equipment you have access to.
N/A because I will be training in-person only at TD Athletes Edge
Dumbbells
Kettlebells
Barbell
Landmine
Cable Machine
Cardio Equipment
Turf
Mini-Bands (small bands)
Long Resistance Bands
Sled
TRX
Physio Ball
Jump Rope
Sliders
Chin-Up Bar
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Please include any additional information about the equipment below:* This field is required.I.e. weight amounts for dumbbells or kettlebells, type of resistance bands and so forth.
Write in N/A if you are training with us in-person
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(Online Only) Please Upload a picture of your training space
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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(Online Only) Please upload an image of your training space
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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If scheduling a Virtual Assessment, do you prefer FaceTime (Phones Only) or Zoom?* This field is required.
I prefer FaceTime
I prefer Zoom
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What would you like to do next?
Get More Information
Book an Assessment
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SignatureBy signing this document or continuing with treatment, I hereby consent to receive therapeutic services provided by TD Athletes Edge, including but not limited to Class IV Laser Therapy, RPW2 Shockwave Therapy, Physical Therapy, Massage Therapy, Custom Coaching and Movement Sessions. I acknowledge that these services are administered by licensed or certified professionals, and I understand the nature, purpose, potential risks, and expected benefits of each modality. I understand that Laser and RPW2 Shockwave therapies are FDA-cleared, non-invasive interventions designed for the temporary relief of musculoskeletal pain, spasm, and circulation improvement, and that physical therapy interventions may include manual therapy, exercise, and the application of physical agents. I further understand that therapeutic results vary by individual, and no guarantees or warranties have been made as to the outcome or duration of benefits.I acknowledge that certain procedures may cause temporary discomfort, soreness, or aggravation of pre-existing conditions. I understand that protective eyewear is required during laser treatments, and I will comply with all safety protocols and pre-treatment instructions, including the removal of reflective objects. I affirm that I have disclosed all known medical conditions and physical limitations, and I agree to notify TD Athletes Edge in writing of any changes to my health status prior to subsequent sessions. I understand that massage therapy services rendered are not intended to diagnose or treat medical conditions, and I am responsible for seeking care from a licensed physician for any underlying health concerns. In consideration of the services provided, I, on behalf of myself, my heirs, and assigns, do hereby release and hold harmless TD Athletes Edge, its employees, officers, and agents from any and all claims, liabilities, or causes of action arising out of or related to the performance of said services. We are located at 63 1/2 Jefferson Ave in Salem MA. There is parking to the right of the building. You will enter the door marked TD Athletes Edge. Once you enter the building you will have a seat or wait in the waiting area right inside the door. I will meet you at the time of your appointment. Please wear or bring workout clothes that allow you to move freely and allow me to get directly to the areas we will be working on (ie. shorts for hips & knees or tank tops/sports bras for shoulders). We do have a 24 hour cancellation policy. If you have to cancel within 24 hours of your appointment time, you will be charged for the appointment. Please text us if you need to cancel and it is within the 24 hour window (at which point you cannot cancel on the square app) 978-712-0260
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