Athletic Development Program Intake Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Day
Month
Year
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Country Code
Phone Number
5
What is your main sporting activity?
6
Do you have any specific training goals?Please Describe.
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Large
Normal
Small
Ok
Ok
7
How motivated are you to achieve this goal?
Not motivated
Motivated
Extremely Motivated
8
To you see any potential barriers to achieving this goal?Please describe.
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Small
Ok
Ok
9
How many times do you exercise per week?Includes any form of exercise or sporting acrtivity.
1-3 x per week
4-5 x per week
5+ x per week
10
Do you regularly participate in some form of strength training?
YESNO
11
How many times per week?
Nil
1-2 x per week
3-4 x per week
5+ x per week
12
What type of strength training do you most prefer?
Free Weights
Machine Weights
Bodybuilding
Olympic Lifting
General
Combination
13
Do you regularly complete some form of running training?
YESNO
14
On average how many km's would you run per week
Nil
0 - 15 km
15 - 30 km
30 - 45 km
45+ km
15
What type of running training do you most prefer?
Interval training
Long runs
Track Sessions
Combination
N/A
16
Do you regularly participate in a sporting activity? (incl. games, training, coaching sessions)eg. AFL, Soccer, Golf, Basketball
YESNO
17
How many times per week would you participate in any sporting activity?
Nil
1-2 x per week
3 -4 x per week
5+ x per week
18
How would your rate your current fitness level?
Poor
Below Average
Average
Above Average
Excellent
19
How would you rate your current nutritional habits?
Poor
Below Average
Average
Above Average
Excellent
20
How would you rate your current sleep quality?
Poor
Below Average
Average
Above Average
Excellent
21
Do you currently have any pain or limitations to any of the following areas?
Neck
Back
Shoulder
Elbow/ Wrist/ Hand
Hip/ Groin/ Pelvis
Knee
Ankle/ Foot
Hamstring
Quadricep
Calf
22
Please describe any injuries or pain
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Large
Normal
Small
Ok
Ok
23
Have these injuries or pain restricted your capacity to perform or train in the last 3 months
YESNO
24
List any exercises or movements that you can't currently perform
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Ok
25
List any previous significant injuries or surgeries
26
Do you or have you suffered from any of the following?
Cardiac/ Heart/ Vascular Conditions
Respiratory Conditions (eg. asthma, emphysema)
Auto-Immune Disorder
Cancer
Diabetes
High Blood Pressure/ High Cholesterol
Previous Stroke
Epilepsy
Rheumatoid arthritis
Vision/ Hearing deficit
Osteoporosis
Osteoarthritis
27
Are you currently or have you previously worked with other performance/health professionals?
Physiotherapist
Strength & Conditioning Coach
Sports Coach (e.g. golf pro)
Chiropractor/ Osteopath
Dietitian
Personal Trainer
Sports Doctor
28
If you are happy to please provide their contact details so we contact them if required
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Small
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Ok
29
What type of equipment will you have access to?
Fitness Centre/ Gym
Free Weights
Kettlebells
Squat Rack
Resistance Bands
Medicine Balls
GPS watch
Heart Rate Monitor
Treadmill
Foam Roller
30
Is there anything else you wish to tell us?
31
I give consent for all or part of the online consultations to be recorded. These recordings will only be used to provide you with information or feedback regarding your program and will not be shared with any third parties without consent.
YESNO
32
I give consent to The Performance Division to discuss my current program or condition with other medical professionals or coaches if required.
YESNO
33
I am aware that participating in Fitness/ Strength Training has inherent risks. I freely accept and fully assume all such risks, dangers and hazards and the possibility of personal injury, death, property damage or loss.
YESNO
Should be Empty: