Intake Form - MISSION: Capable.

This form will be used to inform me of your current status to allow me to know you as well as possible before prescribing anything. Fill it out as completely as possible. Every block is required, so if something is not applicable to you, put “not applicable” or “N/A”.

You may want to prepare your longer, more thorough responses and also save them in a Word document or Google Doc in case there is an email or website failure. It will also let you more easily edit it and review it before submitting.

Contact me with any questions.

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Name

Gender

Height (inches)

Weight (pounds)

Age

Current Health: Describe your current health and current physical condition.

Goals: What are your goals with this program?

Time: How much time do you have to dedicate to your training? Days per week, hours per session, etc.

Training History: Tell me about your current exercise routine and also your training history.

LIfestyle: Explain your current lifestyle, i.e type of job, recreational pursuits, high stress or low stress, how active you are, etc.

Diet: Explain your current and past diet. Include any supplements you take or have taken recently.

Dietary Restrictions: Do you have any dietary restrictions? Any foods you can't/won't eat or any types of foods you prefer to eat?

you any that

Available Equipment: What types of facilities and types of equipment do you have access to?

Physical Limitations: Do you have any physical limitations? Past injuries? Medical conditions?

Preferences: Do you have any particular types of training or exercises that you do or do NOT like? Do you have any specific requests regarding the program design?

Anything Else? Is there anything not already covered that is useful for me to know to prepare your program?

Acknowledgement of Terms & Conditions

I have read and consent to the terms and conditions of this site as indicated below.

All content is being offered for education and information purposes. There is inherent risk with any physical activity. Please consult your physician before starting any exercise or diet program. MISSION: Capable cannot be held responsible for any injury that may occur while participating in any training or diet programs derived from information gained or products purchased on this site. By using any information or purchasing any items on this site, you agree not to hold MISSION: Capable and its authors responsible for any adverse consequences that may arise.