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About
Michael
Giving Back
Syphon Fitness Awards and Press
Client Testimonials
Services
Online Virtual Sessions
Personal Trainer
Post Rehabilitation with Corrective Exercise
Yoga Therapy
Resources
Intake Form
Liability Waiver
Resources
Blog
Contact
Intake Form
Please complete the form below to work with Syphon Fitness.
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Last Name
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Zip
Phone
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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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