Pre-intake question form

Name

Surname

Date of birth

Place of birth

Full address (street, house number, postal code, city)

Phone

Email

What is your occupation?

Are you in pain? if yes please specify

Are you overcoming an injury/surgery? If yes, please elaborate

Do you have scoliosis? If yes please elaborate

Are you currently doing one or more of the following:

Please specify sport/movement

How willing are you to stop doing these activities during your recovery/while initially learning FP in a scale of one to five where one is unwilling and five is very willing?

Are you actually a fitness professional, movement coach, manual or physical therapist? If yes please specify

What is your nutritional preference?

Vegan

Vegetarian

Pescatarian

Other please specify here after

New Field:

How willing are yoo to change your diet in a scale from one to five where one is unwilling and five is very willing?

How many hours sleep/night do you have average? please describe your sleeping pattern (if awake moments at night specify reasony, awake and snoozing wake-up call or full of energy)

Have you completed or are you working on the FP 10-week online program?

Are you interested in Personal Training sessions?

yes

no

maybe

Are you interested in group classes?

yes

no

maybe

What days and times are you willing to workout

Please specify the times per above selection

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

yes

no

Do you feel pain in your chest when you perform physical activity?

yes

no

In the past month, have you had chest pain when you were not performing any physical activity?

yes

no

Do you lose your balance because of dizziness or do you ever lose consciousness?

yes

no

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

yes

no

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

yes

no

Do you know of any other reason why you should not engage in physical activity? New Field

Any furthe info you want to share with us?

Pre intake questions