Rebel Sports Performance logo

Client Intake Questionnaire

Tell us about you, your health, and your goals so we can build a program that fits. It takes about 5 minutes. Your answers stay confidential.


Part 1Personal & Contact Information
Gender
Part 2Lifestyle & Daily Habits
Daily activity level at work
Average hours of sleep per night
General stress level
How would you describe your nutrition?
Part 3Medical History & Safety (PAR-Q)

Please answer honestly. This keeps your training safe and effective.

Please answer Yes or No to each question.

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

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

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness, or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by physical activity?

Are you currently taking medication for blood pressure or a heart condition?

Do you know of any other reason you should not do physical activity?

Part 4Training Goals & Preferences
Primary goalsSelect up to 3.
0 of 3 selected
5
1: Just exploring10: Ready to start now
Days per week you can commit to training
Preferred training time
Current training experience
Acknowledgment