INTAKE QUESTIONNAIRE

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INFO@PMR-PERFORMANCE.COM

Please complete prior to training start date.

If under age 18 a parent or legal guardian signature required.

ATHLETE INTAKE QUESTIONNAIRE

form

Athlete Intake Questionnaire

Athlete Full Name*

Date of Birth*

Phone*

Email*

Address

City

State

Emergency Contact*

Emergency Phone*

Sport & Training

Sport/s Played*

Position/s*

What are your training goals?*

What types of exercise do you participate in or enjoy?

How many times a week do you currently exercise?

Agent Info (if applicable)

Agent Name

Agency

Phone

Health History

Have you ever been diagnosed with a heart condition?*

Yes

Do you experience chest pain during physical exertion?*

Yes

Do you have high or low blood pressure?*

Yes

Do you have asthma or other respiratory issues?*

Yes

Do you have diabetes or any metabolic diseases?*

Yes

Have you ever had surgery or a serious injury?*

Yes

If yes, please describe surgery or injury and provide date.

Do you have any known allergies?*

Yes

If yes, please list.

Are you currently taking any medications?*

Yes

If yes, please list.

Do you have any joint or muscle problems that could be aggravated by exercise?*

Yes

If yes, please describe.

Are there any other medical conditions or physical limitations we should be aware of?

Consent

I, the undersigned, affirm that the information provided above is accurate to the best of my knowledge. I understand that it is my responsibility to consult with a physician prior to participating in any exercise program.

Signature*

Date*

Parent/Legal Guardian Name (if under 18)

Parent/Legal Guardian Signature

Date

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