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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.
First & Last Name
EMAIL
Birthdate (dd/mmm/yy)
Height
Weight (If you know it. If you don't, don't worry and you will not have to answer this again!)
What is your occupation / How do you spend your days?
What is your current, #1 training goal?
Do you prefer to workout at home or in a gym?
Please list all workout equipment you have at home. Be as specific as possible. Do you prefer resistance bands, dumbbells, or something else?
What is your current training / workout schedule (if any) and routine? (Example: bootcamp for 45 min, twice a week, no activity, weight lifting 3x/week, etc.)
If you don't own dumbbells, massage balls, or resistance bands, are you willing to purchase any of those things?
Current Training/Workout Schedule (if any) and Type (Example: bootcamp for 45 min, twice a week, no activity, weight lifting 3x/week, etc.):
Thinking long-term, how many days can you eventually commit to working out each week and for how long? (This does not mean this is where you will begin :) *
Injuries / Medical History of which we should be aware:
Current Medications / Supplements:
Current Daily Water Intake
Favourite foods:
Least favourite foods:
Thinking about feeding my body the nutrients it needs: (check all that apply)
I listen to my body, eating when I'm hungry and stopping when I'm full
I eat foods that help me feel full and energized (when available)
I am aware of foods that make me feel lethargic or jumpy (or otherwise unwell) and avoid them when possible
I typically feel mentally alert and sharp
My current movement habits (check all that apply):
I find ways to move my body each day
I know when my body needs to rest or take a break
I feel connected to my body's energetic needs overall
I notice shifts in how I feel when I move my body
Which of the following describe your current situation and dealing with stress? (check all that apply)
I am aware of how the people in my life affect my stress level
I am aware of how the content I consume (social media, news, entertainment) affects my stress level
I know when I'm stressed out and find moments to calm myself whenever possible
I find stillness, quiet, or nature for at least a few moments each day
Do you prefer?:
*
card decks
paper books
journals
Are you willing to journal on paper?
yes
no
Rate Your Sweet Tooth on a scale of 1-10:
Tell us about your support system. Do your coworkers, family & friends hinder or support you?
ParQ1. Has your doctor ever said that you have a heart condition or high blood pressure?
yes
no
ParQ2. Do you feel pain in your chest at rest, during your regular activities of living, or when you do physical activity?
yes
no
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.)
yes
no
ParQ4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure?
yes
no
ParQ5. Are you currently taking prescribed medications for a chronic medical condition?
yes
no
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)
yes
no
ParQ7. Has your doctor ever said that you should only do medically supervised physical activity?
yes
no
Any concerns, doubts, or anything else you'd like us to know? xo
Submit
Thanks! We’ll contact you shortly.
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