Training Intake Form

New customer? Please complete this Training Intake Form prior to your first meeting with a S.P.A.R.T.A. representative.

First Name:		*  Ex: Mary
Last Name:		*  Ex: Smith
Email Address:		*  Ex: msmith@domain.com
Phone:		*  Ex: 703-555-5555

Please check all that apply:

Condition		Self	Family History
1.	Arthritis (Explain Below)
2.	Blood Clots
3.	Cancer/Tumors
4.	Chronic Pain (Explain Below)
5.	Depression
6.	Diabetes
7.	Fatigue
8.	Headaches
9.	High/Low Blood Pressure
10.	Muscle or Joint Pain (Explain Below)
11.	Numbness/Tingling (Explain Below)
12.	Other that may impact your ability to work out (Explain Below)
13.	Scoliosis
14.	Sinus Problems
15.	Sleep Difficulties
16.	Sprains/Strains (Explain Below)
17.	Tendonitis (Explain Below)
18.	Varicose Veins
19.	Vision Problems

Explanation of any conditions listed above that require more detail:


Medications that you are currently taking:


Allergies that you have:


Previous major injuries/surgeries:


Current or ongoing medical treatment you are receiving:


Physical activities that you participate in regularly:


How many times per day do you usually eat?


Primary activity at work: (i.e. On phone, sitting, computer, driving, etc.)


What do you do to relieve stress?


Why are you a good candidate for this program?

Medical Contact Information It is important that we communicate with other medical professionals responsible for your health. We may need to contact them to educate the proper professionals on the details of your program with S.P.A.R.T.A.. This way, we can work closer together to fully obtain the best health and fitness possible for you. S.P.A.R.T.A.'s scope of practice does not involve the prescription of drugs, diagnosis or treatment of conditions or injuries, manipulation of skeletal structures, or application of therapeutic modalities. S.P.A.R.T.A. leaves those techniques to those respective specialists. Likewise, it is important that these professionals let S.P.A.R.T.A. know all of the pertinent client information so that a S.P.A.R.T.A. Training™ specialist can properly prescribe the correct, safe, and custom exercise plan. This information is particularly important if you are a client that has special considerations such as hypertension, diabetes, or cardiovascular disease. It is also important if you have orthopedic injuries and/or are engaged in a post-rehab program with us. Please list the contact information for your primary doctor, orthopedist, physical therapist, chiropractor, or other relevant medical professionals.
Doctor Name:
Speciality:
Phone or Email:
Doctor Name:
Speciality:
Phone or Email:
Doctor Name:
Speciality:
Phone or Email:

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