Intake Form

Intake Form

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Date of Birth

Doctor Name

Doctor Phone

What do you want to gain from working with me?

How did you hear about me?

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Since you 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

Describe your daily activities (Home, Work, Play)

Do you have any injuries?

Yes

Please describe your injury.

How long have you had this injury?

What caused your injury?

Have you had any surgeries?

Yes

Please describe your surgeries. (Include approximate date)

List any other limitations you may have physically.

Mental Health

Do you feel depressed at times?

Yes

Do you know of any circumstances that may cause the depression?

Do you feel anxious at times?

Yes

Do you know of any circumstances that may cause the anxiety?

Medication/Supplements

Are you taking any Prescription Medication?

Yes

Please list all medications and dosages.

Are you taking any Supplements?

Yes

Please list all supplements.

Please complete the form below to work with Syphon Fitness.

Client Medical History

Physical Conditions

Mental Health

Medication/Supplements

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