• Client Intake Form

    Client Intake Form

  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Physical Activity Readiness Questionnaire

  • Have you ever been advised by a doctor that you have a heart condition and should only do physical activity recommended by a doctor?*
  • Have you ever been told that you have high blood pressure?*
  • Do you ever feel pain in your chest when you perform physical activity OR when doing general activities of daily living?*
  • Have you ever had chest pain when you are not doing physical activity?*
  • Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).*
  • Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.*
  • Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*
  • Do you suffer from any allergies?*
  • Are there any other reasons not mentioned why you should not exercise?*

  • Medical and Pregnancy History

  • Are you currently under a medical professional's care (i.e. OB, MD, Midwife, etc)?*
  • Are you currently pregnant?*
  • Any recent hospitalizations or surgeries?*
  • Delivery History
    Rows
  • Have you experienced complications in previous pregnancies?
  • Are you breastfeeding? (Yes, pumping counts!)

  • Symptoms

  • Have you recently visited a Pelvic Floor Physical Therapist?*
  • Do you experience any of the following?*
    Rows

  • Thinking back over the last 30-60 days, please rate the following areas:

  • Athletic History

  • Have you continued exercise through previous pregnancies?
  • Have you continued exercise through previous pregnancies?

  • Availability

  • Please select the best days you can exercise.*
  • Please select the best times you can exercise.*

  • Release and Acknowledgement

  • I, {clientName}, hereby acknowledge that the information I've given above is complete and accurate. I am informed that my information in this form will be kept confidential.

    I release and discharge the fitness coaches, administration and workers from any disclosure of my personal information in this Client Intake Form.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: