Initial Assessment

Thank you for your interest in getting started with us!

Please fill out the following form as completely and accurately as you can.  There are some fields that are required, simply so that we have that information on hand up front to be able to understand your situation and help you out as best as we can in a safe and productive manner.

[contact-form]

Personal Information

[contact-field label=’First Name’ type=’name’ required=’1’/]
[contact-field label=’Last Name’ type=’name’ required=’1’/]
[contact-field label=’Email’ type=’email’ required=’1’/]
[contact-field label=’Phone Number’ type=’text’/]
[contact-field label=’Location (City, State, Country?)’ type=’text’/]
[contact-field label=’Date of Birth’ type=’text’ required=’1’/]
[contact-field label=’Gender’ type=’select’ options=’Female,Male’/]
[contact-field label=’Height’ type=’text’/]
[contact-field label=’Weight’ type=’text’/]

Life Style History

[contact-field label=’Occupation’ type=’text’/]
[contact-field label=’Average hours a week that you work?’ type=’text’/]
[contact-field label=’Average hours a night that you sleep?’ type=’text’/]
[contact-field label=’Average hours a week that you train?’ type=’text’/]
[contact-field label=’How many years have you been training?’ type=’text’/]
[contact-field label=’Type of training? (run, bike, yoga, swim, Pilates, kickboxing, etc)’  type=’textarea’/]
[contact-field label=’Have you had a coach before?’ type=’text’/]
[contact-field label=’Why are you seeking a coach now?’ type=’textarea’/]
[contact-field label=’What are your goals?’ type=’textarea’/]
[contact-field label=’How many meals do you eat in a day?’ type=’text’/]
[contact-field label=’What do you eat in a typical day?’ type=’textarea’/]

Medical History

[contact-field label=’Do you smoke?’ type=’select’ options=’Yes,No’ required=’1’/][contact-field label=’Are you pregnant?’ type=’select’ options=’Yes,No’ required=’1’/][contact-field label=’Has a physician ever said that you have a heart condition, or should only perform physical activity recommended by a physician?’ type=’select’ options=’Yes,No’ required=’1’/]
[contact-field label=’When you perform mild physical activity or exertion, do you feel pain in your chest?’ type=’select’ options=’Yes,No’ required=’1’/]
[contact-field label=’Do you ever lose your balance, or lose consciousness due to dizziness?’ type=’select’ options=’Yes,No’ required=’1’/]
[contact-field label=’Do you have any joint or bone problems that could worsen by change in physical activity?’ type=’select’ options=’Yes,No’ required=’1’/]
[contact-field label=’Do you have insulin dependent diabetes?’ type=’select’ options=’Yes,No’ required=’1’/]
[contact-field label=’Do you have any other medical conditions? (Asthma, poor circulation, hernia, high blood pressure, etc)’ type=’textarea’ required=’1’/]
[contact-field label=’List any medications you take, including over the counter, behind the counter, herbal, etc.’ type=’textarea’ required=’1’/]
[contact-field label=’Have you had any injuries? (Broken bones, separated shoulder, sprained wrist, etc)’ type=’textarea’ required=’1’/]
[contact-field label=’Do you have any current injuries or pains?’ type=’textarea’ required=’1’/]
[/contact-form]

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