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Muscles & Mindset New Client Intake Form
At least 24 hours before your Orientation Call, please take a moment to fill out our online intake form.
Thinking about feeding my body the nutrients it needs: (check all that apply)
My current movement habits (check all that apply):
Which of the following describe your current situation and dealing with stress? (check all that apply)
Do you prefer?:
Are you willing to journal on paper?
ParQ1. Has your doctor ever said that you have a heart condition or high blood pressure?
ParQ2. Do you feel pain in your chest at rest, during your regular activities of living, or when you do physical activity?
ParQ3. Do you lose your 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.)
ParQ4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure?
ParQ5. Are you currently taking prescribed medications for a chronic medical condition?
ParQ6. 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 physically active? (Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active)
ParQ7. Has your doctor ever said that you should only do medically supervised physical activity?

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