FIIT Squad - Client Intake form

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FIIT Squad - Client Intake form

General Info & Medical Verification

First and Last Name *

Email address *

Address *

Date of Birth

YYYY

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact relationship (ex. Husband, wife, mother, father etc) *

Par-Q Exercise Readiness Questionaire

General Health Questionnaire for exercise clearance (*if answered yes to any questions below, must have been cleared by your doctor before commencing exercise)

Has your doctor ever said that you have a heart condition or high blood pressure? *

Yes

Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

Yes

Do you lose 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

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

Yes

Are you currently taking prescribed medications for a chronic medical condition?

Yes

If answered yes to the question above please list medications. *

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

If you have any bone or joint limitations that you may require modifications for that you think would be helpful for the trainers to be aware of please list below. (ex. plantar fasciitis, sore shoulder etc) *

How did you hear about FIIT Squad *

Social Media (facebook group, IG etc)

Local to the area and walked by - in the neighborhood

Google Search

Referred by a friend or family

Website

Required

Would you like to subscribe to our newsletter to stay up to date with studio news, events and promotions?

Yes

Clear selection

I consent that all the above information is correct and up to date, and give permission to the sharing of this information amongst the other trainers and staff at FIIT Squad if necessary.
*

Yes

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