Intake Form

Please complete the form below to work with Syphon Fitness.

Intake Form
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Do you know of any other reason why you should not engage in physical activity?

If you have answered “Yes” to one or more of the above questions, consult your physician
before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Client Medical History

Physical Conditions

Do you have any injuries?
Have you had any surgeries?

Mental Health

Do you feel depressed at times?
Do you feel anxious at times?


Are you taking any Prescription Medication?
Are you taking any Supplements?