Intake Form - Empowerment Fitness

Base Intake Form v3

"*" indicates required fields

Step 1 of 3

33%

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Product ID

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Date

MM slash DD slash YYYY

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Contract Starts Date

MM slash DD slash YYYY

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Contract Expires Date

MM slash DD slash YYYY

Personal Information

Name*

First Last

Email*

Mobile Phone No.*

Birthdate*

MM slash DD slash YYYY

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Male

Female

Current Fitness Status

Preferred unit of measurement*

Metric (kg, cm)

Imperial (lbs, in)

Weight (kg)*

Height (cm)*

Weight (lbs)*

Height (in)*

Body fat %*

If you don't know your current body fat percentage, please reference the image below to give us your best estimation.

Please enter a number from 3 to 40.

Female body fat reference images

Male body fat reference images

What is your current training level?*

If you are in-between levels, select the lower level.

Beginner

Intermediate

Advanced

Primary goal*

Lose weight

Gain muscle

Maintenance

At what pace do you wish to achieve your goal?*

Slow

Medium

Fast

Equipment access*

Full gym

At home

Kindly select the equipment that you possess at your home.*

Dumbbells

Kettlebells

Barbell and Bench

Meal Plan Preferences

Do you have any dietary restrictions or preferences?*

No Preferences

Vegan

Vegetarian with eggs

Vegetarian with dairy

Vegetarian with eggs and dairy

Pescatarian

Paleo

Select any foods you would like to avoid

Dairy

Eggs

Fish

Gluten

Meat

Peanuts

Shellfish

Soy

Tree Nuts

Lifestyle and Preferences

What is your current activity level?*

Sedentary

Lightly active

Moderately active

Very active

Extra active

How many days per week would like to workout?*

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What habit(s) would you like to work on? (Limit 3 please)

Eat protein

Eat good fats

Eat complex carbs

Eat vegetables

Follow portion guides

Practice eating slowly

Eat until 80% full

Prepare your own meals

Drink only zero-calorie drinks

Abstain from alcohol

Take a more active route

Make it easier to work out

Do an enjoyable activity

Recruit social support

Reward yourself after workouts

Prioritize self-care

Celebrate your wins

Digital detox before bed

Practice a bedtime ritual

Current injuries*

Lower back

Shoulder

Hips

Knees

None of the above

Physical activity readiness questionnaire (PAR-Q)

Regular physical activity is fun and healthy for most people, however, all participants should check with their doctor before starting an exercise program. If you are planning to use Pride Fitness and Nutrition, you must answer the seven questions below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you are required to check with your doctor and obtain a Physician’s Medical Release Form before you start. If you are over 69 years of age, you are required to check with your doctor and obtain a Physician’s Medical Release Form prior to using Pride Fitness and Nutrition. Common sense is your best guide when you answer these questions. Please read each question carefully and answer each one honestly. Check Yes or No.

1. Has your doctor ever said you have a heart condition and recommended only medical supervised physical activity?*

Yes

2. Do you have chest pain brought on by physical activity?*

Yes

3. Have you developed chest pain within the past month?*

Yes

4. Do you tend to lose consciousness or fall over as a result of dizziness?*

Yes

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5. Do you have a bone or joint problem that could be aggravated by the proposed physical activity?*

Yes

5. Has a doctor ever recommended medication for your blood pressure or a heart condition?*

Yes

6. Are you aware, through your own experience or a doctor's advise, of any other physical reason against you exercising without medical supervision?*

Yes

If you answered YES to one or more questions, or are over the age of 69:

Consult with your physician concerning your YES answers on the PAR-Q.
Obtain a Physician's Medical Release Form prior to using the services of Empowerment Fitness

Delay becoming much more active:

If you are not feeling well because of temporary illness such as cold or fever - wait until you feel better.
If you are or may become pregnant, talk to your doctor and receive a Physician's Medical Release Form prior to utilizing Empowerment Fitness services.

Please Note:

If your health changes so that you then answer YES to any of the above questions, your age exceeds 69, or you become pregnant, you are responsible for informing Empowerment Fitness and will be required to obtain a Physician's Medical Release form.

Photo consent*

I hereby give permission and authorize Empowerment Fitness to make use of my progress photos for social media and other marketing efforts

I do not give permission and authorize Empowerment Fitness to make use of my progress photos for social media and other marketing efforts