Initial Intake Form
This questionnaire is designed to help me learn what I need to know to help you stay safe and healthy during exercise while reaching your goals. Please take your time and fill out this questionnaire as honestly as possible. The information gathered in this form will be kept confidential.If you have any questions, please send me an email and I will respond as soon as I'm able.I look forward to diving deeper into your training goals and discussing a game plan during our consult!
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What's the best way to contact you?
Text
Phone Call
Email
DM/Social Media
Date of Birth
-
Month
-
Day
Year
Date
Sex
Please Select
Female
Male
Other
Prefer not to say
Emergency Contact
Name + Phone # + Relationship to You
Permission to contact medical professional team if needed to collaborate on a treatment plan? (Primary Health Care Provider (doctor), Physio, Naturopath, etc.)
Please Select
Yes
No
Depends
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What service are you applying for?
Please Select
1:1 Individualized Remote Coaching
1:1 Personal Training
Semi Private Personal Training
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Par-Q Form
The physical activity readiness questionnaire (PAR-Q) is a self-screening tool designed to determine the safety or possible risks of exercising based on your health history, current symptoms, and risk factors.
Has your doctor ever said that you have a heart condition or high blood pressure?
Yes - Heart Condition
Yes - High Blood Pressure
No
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?
Yes
No
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).
Yes
No
Have you ever been diagnosed with another chronic medical condition (other than heart diseaseor high blood pressure)?
Yes
No
Are you currently taking prescribed medications for a chronic medical condition?
Yes
No
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 physicallyactive? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.
Yes
No
Has your doctor ever said that you should only do medically supervised physical activity?
Yes
No
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Establishing Boundaries
Throughout our coaching partnership, there may be things that come up that you are or arenot comfortable talking about. Topics such as your menstrual cycle, pelvic floor health, nutrition, sleep, and stress may all have an impact on your training and your results to varying degrees. Please indicate which topics you are comfortable talking about with me by checking the relevant boxes (or checking the first box if you are comfortable talking about all of them). If you are not comfortable talking about a certain issue with me, leave the box(es) blank. You may change your decision at any time. As you go through the rest of this form, feel free to leave any questions you don’t feel comfortable answering blank.
I am only comfortable talking about these specific topics:
I am comfortable talking about all of the topics listed below
Menstrual cycle
Pelvic floor health
Incontinence
Pelvic organ prolapse
Menopause
Nutrition
Eating habits and behaviors
Sleep
Stress
Emotional Issues & Mental Health
Body Image
Weight
Other
Cues & Assessments: Consent
During an in person assessment and/or training session, there may be instances where it can be helpful for me to manually cue or manually assess you, which requires physical touch. In addition to your consent here, I will also obtain your verbal consent before manually cueing or assessing you during a training session. *If working 100% remotely, feel free to leave your response blank.
Please indicate which body parts you are comfortable having me manually cue or assess by checking the relevant boxes (or checking the first box if you are comfortable having me manually cue or assess all of them). If you are not comfortable having certain areas (or any part of your body) touched for cueing or assessment, leave the box(es) blank. You may change your decision at any time.
I am comfortable with my coach manually cueing and manually assessing all the body parts listed below
Feet
Legs
Hands
Arms
Head
Glutes
Abdomen
Upper Back
Lower Back
Neck
Other
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Medical History
Do you have a previous history of injury, pain, or physical limitations with any body parts? If so, please explain:
Have you ever had surgery? If so, when and for what:
Are you currently experiencing or have you recently experienced any muscle or joint pain?
Yes
No
Unknown
If you answered yes, please explain:
MUSCULOSKELETAL
Do you currently or have you ever experienced any of the following? If so, please check the applicable boxes.
Central pubic area pain
Coccyx (tailbone) damage or pain
Lower back pain
Abdominal bulging or doming
Neck pain
Knee pain
Other
Have you experienced the feeling of "Pins and needles" and if so, where?
Yes/No + Location (if yes)
Have you experienced the feeling of "shooting or radiating pain' in back, glutes, or legs?
Yes/No + Location
PELVIC HEALTH
Do you currently or have you ever experienced any of the following? If so, please check the boxes.
Heaviness, dragging, or bulging in the pelvic area
Pain in the pelvic area
Diagnosis of pelvic organ prolapse
Leaking urine while coughing, sneezing, exercising, or exerting yourself
Strong and sudden urge to urinate
Leaking of urine at rest
Difficulty or discomfort w/ passing urine
Uncontrollable gas
Leaking of feces
Straining during bowel movements
Pain in the perineum during sexual intercourse (or any other time)
Unexplained bleeding during or after exercise
Other
Do you currently or have you ever experienced any of the following? If so, please check the boxes.
Hemorrhoids
Varicose veins
Constipation
Gestational diabetes
Low blood pressure
Preeclampsia
High blood pressure
Have you met with any of the following healthcare professionals in the past 12 months?
Physiotherapists
Acupuncturists
Chiropractors
Other
Please describe the reason(s) for your visit(s):
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Your Past Birth Experience(s)
Please fill out this section if you’ve experienced birth in the past. If you haven’t, skip down to“Your Health Details.”
Date(s) of birth:
Birth type:
Vaginal
Assisted
C-Section
Tearing (if known)
Please Select
None
Unsure
First Degree
Second Degree
Third Degree
Fourth Degree
Are you currently breastfeeding?
Yes
No
Is there anything else you want me to know about your past birth experience(s)?
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Your Health Details
Have you been diagnosed (currently or in the past) with any significant medical conditions and/or injuries that you haven’t mentioned yet? Please check all that apply.
Heart condition
Asthma
Cancer
Type 1 diabetes
Type 2 diabetes
Autoimmune condition
Thyroid disease
Seizures
Fibromyalgia
Arthritis
Blood disorder
Osteoporosis
Knee pain or injury
Neck pain or injury
Back pain or injury
Other
Use the space below to provide details on any boxes checked above.
Are you taking any medications, either over-the-counter or prescription? If so, list them all below.
Have you ever had surgery or experienced any other major medical event you want me to know about? If so, use the space below to share what happened, and when.
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Your Training
In general, what are your goals for training? Check all that apply.
Gain strength
Gain muscle
Gain body weight
Lose body fat
Improve aerobic fitness
Reduce aches and pains
Improve overall health and wellness
Manage or improve my mental health
Have fun and enjoy fitness
Other
Out of the goals you checked, which ones feel most important? Please rank your top 3.
During a typical week, what types of activity are you currently engaging in and how often?
How’s your exercise routine working for you right now? What, if anything, do you want to change?
How much time can you devote to your training each week? Please explain briefly.
What types of training have you done in the past five years, if any? Did it help you achieve the results you were looking for?
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Your Lifestyle
The purpose of the following questions is to help me, as your coach, get a better understanding of your lifestyle. Sleep, nutrition, hydration, and stress all affect your training and recovery.When I have a better understanding of these factors, I can modify your workouts accordingly to ensure you can recover. It also helps us work together to make sure your program leaves you feeling strong and energized.
STRESS AND RECOVERY
How much sleep do you get in a 24-hour period?
Less then 4 hours
5-6
6-7
7-8
8-9
10+
Rate your general stress level on a scale of 1–10:
Little
1
2
3
4
5
6
7
8
9
Extreme
10
1 is Little, 10 is Extreme
Rate your general energy level on a scale of 1–10:
Exhausted
1
2
3
4
5
6
7
8
9
Fully Energized
10
1 is Exhausted, 10 is Fully Energized
Do you feel depressed or anxious?
Please Select
Yes
No
Maybe
Have you ever been diagnosed with depression or anxiety?
Please Select
Yes
No
Nutrition
How much water do you drink in a 24-hour period?
# of cups or Litres
Who does most of the grocery shopping & cooking in your household?
Do you have food allergies/food preferences?
Lactose intolerance
Celiac
Nut Allergy
Vegan
Vegetarian
No dietary restrictions
Other
What does your nutrition look like on a “typical” day. Please list meals, snacks, and beverages.
What, if any, changes would you like to make to how you’re eating, and why?
What, if any, vitamins and supplements do you currently take?
ENVIRONMENT
Who do you live with? (e.g., spouse/partner, parents, roommates, pets, children)
What, if any, major obstacles are you encountering at home or with loved ones when it comes to your efforts to train, eat, and recover?
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INTERESTS
How do you spend your time / what do you do for work?
What are your favorite hobbies?
What is your favorite thing about yourself (physical, mental, personality, etc.)?
What do you believe are your biggest strengths?
What fills you up and brings you joy?
What is your music preferences? (Bonus points if you add a playlist link 😉 )
Applicable for personal training clients
Coaching
What drove you to seek out coaching?
What do you hope to get out of our coaching experience?
What do you expect from me as your coach?
Is there anything else you want to share that you haven’t been asked yet?
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Disclaimer & Release
I, the undersigned, have read, understood to my full satisfaction, and completed questionnaire.
I understand that if my health changes, I must inform my coach and check with my PCP that I’m still cleared for exercise.
I recognize that it is my responsibility to work directly with my PCP before, during, and after seeking fitness and/or nutrition consultation.
I understand that any information provided is not to be followed without prior approval of my PCP. If I choose to use this information without such approval, I agree to accept full responsibility for my decision.
I acknowledge that my coach may retain a copy of this form for their records. In these instances, they will maintain the confidentiality of the same, complying with applicable law.
Signature
This form is complete to the best of my knowledge and understanding as of today's date:
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Month
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Today's Date
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