Athletic Health & Performance Adult Intake Form
Welcome Aboard! Please take your time filling out this form. Bring this to your first session with your Performance Coach.
Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date Picker Icon
Age
Height
*
Weight
*
Address
Phone Numbers
Cell
*
Home
*
Work
*
Emergency Contact
*
Email
*
Sports Coach
Goals & Expectations
Please describe your short-term goals (next 12 weeks)
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Please describe your long-term goals (next 12 months)
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What do you think is the most important thing I can do to help you achieve your goals?
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Your Current Weekly Training Schedule
Monday
*
Tuesday
*
Wednesday
*
Thursday
*
Friday
*
Saturday
*
Sunday
*
PAR Q HEALTH HISTORY
Please circle YES or NO to the questions below.
Has your doctor ever said you have heart trouble?
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Yes
No
Do you frequently have pains in your chest?
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Yes
No
Do you often feel faint or have spells of severe dizziness?
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Yes
No
Has your doctor ever said your blood pressure was too high?
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Yes
No
Are you currently being treated for any medical conditions? Mental or physical?
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Yes
No
If yes, please elaborate.
*
Do you have a bone or joint problem that could be made worse by a change in physical activity?
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Yes
No
Are you currently taking any prescription or over the counter medication that will affect your heart rate’s response to exercise?
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Yes
No
Please list medications
*
Do you suffer from allergies?
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Yes
No
If yes, please elaborate on allergies.
*
Do you suffer from asthma?
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Yes
No
Do you have ANY injuries, past or present we should know about?
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Yes
No
Have you ever been in a car accident?
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Yes
No
Have you ever had any surgeries?
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Yes
No
Have you had any fractures?
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Yes
No
INJURY HISTORY
Please elaborate on injuries.
*
TRAINING EXPERIENCE AND HISTORY
When did you start your sport or training?
*
Current Level
Beginner
Intermediate
Advanced
Current Level
*
Left or Right Dominant?
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Left
Right
Number of Years of FORMALIZED Training Experience
*
Have you ever had supervised strength & conditioning?
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Yes
No
If yes, please describe
*
How do you warm-up for a training session?
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How do you currently improve your level of conditioning?
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Do you have any physical fitness test scores you can share? Squat? Bench? 1.5 mile run etc.?
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What strategies do you use for recovery?
*
NUTRITION QUESTIONS
On a scale of 1-10, how would you rate your nutrition? (1=very poor, 10=excellent)
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1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Do you have guidance in this area?
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Yes
No
How many times a day do you usually eat (including snacks)?
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Do you eat breakfast?
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Yes
No
How many glasses of water do you consume daily?
*
Do you feel drops in your energy levels throughout the day?
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Yes
No
If yes, what time of the day?
Are you currently taking supplements?
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Yes
No
Please list supplements.
*
How many times per week do you eat out?
*
Submit
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