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Pasifika Strength & Conditioning Intake Form

Athlete & Client Intake Form

Please complete the following information. This form helps Pasifika Strength & Conditioning design the safest and most effective training program for you or your athlete.

What program are you interested in?

What program are you interested in?
A
B
C
D
E
Section 1 — Personal Information

Full Name

Age

Phone Number

Email Address

City

Occupation/ School

Emergency Contact Name

Emergency Contact Phone Number

Section 2 — Client Type

Which one do you best fall under?

Which one do you best fall under?
A
B
C
D
Section 3 — Parent / Guardian (Youth Only)

Parent/Guardian Name

Relationship to Athlete

Phone Number

Email Address

Section 4 — Sport Background

Primary Sport

Secondary Sport

Position

Current Team

Years Playing Sport

Competition Level:

Competition Level:
Section 5 — Training Goals

Select all that apply:

Select all that apply:
Top 3 Goals (Next 6 Months):
Section 6 — PAR-Q Health Screening

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

Do you feel pain in your chest during physical activity?

Do you lose balance because of dizziness or lose consciousness?

Is your doctor prescribing medication for blood pressure or heart conditions?

Do you have a bone or joint problem that could worsen with physical activity?

Is your doctor prescribing medication for blood pressure or heart conditions?

Do you know of any reason you should not participate in physical activity?

If YES to any question above, please explain:

Section 7 — Injury History

Previous injuries (check all that apply):

Previous injuries (check all that apply):

Describe injuries or surgeries:

Section 8 — Lifestyle

Average sleep per night:

Nutrition habits:

Nutrition habits:

Current Fitness Level:

Current Fitness Level:
Section 9 — Scheduling

Preferred Training Type:

Preferred Training Type:

Preferred Days:

Preferred Days:

Preferred Time:

Section 10 — Waiver
I certify that the information above is accurate. I understand that participation in strength and conditioning training involves inherent risks.
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