Intake Form | Ten33 Fitness

Welcome to TEN33 Fitness! Please complete this form as accurately as possible so we can build a safe and effective program for you. All information is kept confidential.

Full Name

Birthday

Year

Month

Day

Gender

Occupation

Address

Phone

Email

Emergency Contact

Program Interest & Schedule

Preferred Days

Preferred Times

Fitness Background

Current Activity Level

Sedentary (little/no exercise)

Lightly Active (1-2x/week)

Active (3-4x/week)

Very Active (5+ times/week)

Describe your main fitness goal in your own words

Current exercise routine, if any (activities, frequency, duration)

Previous injuries, surgeries, or physical limitations

Health History Screening

Based on the Physical Activity Readiness Questionnaire (PAR-Q). Please answer honestly — if you answer YES to any question, we recommend consulting your physician before beginning a new exercise program.

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

Yes

No

Do you feel pain in your chest when you do physical activity?

Yes

No

In the past month, have you had chest pain when you were not doing 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 blood pressure or heart medication?

Yes

No

Do you know of any other reason why you should not engage in physical activity?

Yes

No

Current medications

Allergies

Acknowledgment & Signature

I certify that the information provided in this form is true and accurate to the best of my knowledge. I understand staff will use this information to design a program appropriate for my needs, and it is my responsibility to update staff of any changes to my health status.

Signature

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Date