Fight 2B Fit DC Fitness Program Intake & Agreement
Please fill this out and submit prior to your assessment.
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Email *
Name *
First and last name
Birthdate *
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Do you have a physical therapist or physician you would like me to connect with? *
If so, please provide your physical therapist's or physician's contact information here (Please note they may require an additional waiver in order for me to talk to them):
Occupation; Lots of sitting? *
Phone number *
Emergency Contact: Name & Phone *
Health Conditions *
Required
Have you been fully vaccinated for COVID-19? Fully vaccinated is defined as 2 weeks after the second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson's Janssen vaccine. *
Do you smoke? *
Do you drink? *
How many drinks do you consume per week? *
Please describe and list any Injuries or conditions (other than what is mentioned above). Please include date, treatment and current status of the injury and/or condition. Please answer N/A if this does not apply to you. *
Surgery in the last three months? If yes, please explain. *
Describe any medical attention you are currently receiving for any injuries and/or condition. Please answer N/A if this does not apply to you. *
Currently on any medications? *
Which medications? What for? Relevant side effects? Please answer N/A if this does not apply to you. *
Level of Overall Physical Pain *
Specific locations of current pain. Please answer N/A if this does not apply to you. *
Explain any discomfort or anxiety from any kind of activity. Please answer N/A if this does not apply to you. *
What activities do you currently engage in? Sports? Lifting? Gardening? Leisure walking? Running? Group Exercise classes? Etc. Please describe. *
How much time a week do you spend being active? *
How much sleep do you get each night? *
Level of Stress *
Describe your current diet. *
List your top three goals. *
What obstacles have kept you from reaching your goals? *
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