New Client Application Form

New Client Application Form

This application is to train Functional Patterns with FP Human Biomechanics Specialist Nina Tetzlaff. Please answer each question as specifically as possible. Nina will be in contact with you after assessing all parts of this application to determine whether or not training together will go ahead. A large part of this comes down to availability, severity of your health condition and how willing you are to make changes to your current lifestyle that may be impeding you.
Name

First NameLast Name
Birth Date

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What is your home suburb?
What is your gender?
What is your occupation?
How did you hear about us?
TextCallEmail
Why do you want to do Functional Patterns?
Are you in chronic pain?
Are you overcoming an injury?
Please elaborate on your Chronic Pain and / or Injuries if you have any.
YesNo
If yes, please elaborate on your concerns.
Do you have any relevant reports, x-rays, or any other medical imaging scans you'd like to show us? If yes, please upload them below.

Cancelof
RunningSwimmingCyclingFootballSoccerRock ClimbingKayaking / SurfingGymnastics / DancingBoxing / Wrestling / Jiu JitsuYogaLifting WeightsNone of the aboveOther
If other please elaborate on your sports / activities.
How willing are you to stop your current form of activities? (1 being completely unwilling, 5 being most willing)

1

2

3

4

5

1 is Completely Unwilling, 5 is Most Willing
How willing are you to stop these activities during your recovery/while initially learning functional patterns? (1 being completely unwilling, 5 being most willing)

1

2

3

4

5

1 is Worst, 5 is Best
PhysiotherapyChiropractic TherapyMassage TherapyStretch TherapyNone of the aboveOther
If yes please specify how often
YesNo
How willing are you to changing your diet if presented with information that grains can impact your recovery and health? (1 being completely unwilling, 5 being most willing)

1

2

3

4

5

1 is Worst, 5 is Best
YesNo
How willing are you to change your diet if presented with information that a diet containing animal products is essential to your recovery and health? (1 being completely unwilling, 5 being most willing)

1

2

3

4

5

1 is Worst, 5 is Best
YesNo
If yes please specify how often
YesNo
If yes please specify how often
YesNo
If yes please specify how often
Are you currently a fitness or health professional, movement coach, or any sort of health therapist?
What are your goals and expectations?
Have you completed the Functional Patterns 10 week online course and/or the FTS?
What are the best days and times to train? Please give us an idea of your availability. *
By signing this form i confirm that the information provided above is accurate and up to date to the best of my knowledge. I understand that it is my responsibility to inform my trainer of any changes to my health or physical condition.

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