(972) 978-7846
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Stronger Foundations, Better Results

(972) 978-7846
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Intake Form

Please complete the form below to work with Syphon Fitness.

First Name

Last Name

Date

Address

City

Zip

Phone

Date of Birth

Doctor Name

Doctor Phone

How did you hear about me?

What do you want to gain from working with 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 No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Describe your daily activities (Home, Work, Play)

Do you have any injuries?

How long have you had this injury?

What caused your injury?

Have you had any surgeries? If yes, please describe below (Include approximate date)

List any other limitations you may have physically.

Mental Health

Do you feel depressed at times?

Do you feel anxiety at times?

Medication/Supplements

Are you taking any Prescription Medication?

Yes No

If yes, please list.

Are you taking any Supplements?

Yes No

If yes, please list.

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