Athlete Intake
Email address *
Name *
Your answer
Preferred name to be addressed as:
Your answer
How did you hear about Marshall: *
Your answer
Complete Mailing Address:
Your answer
Phone # (Primary) *
Your answer
Cell or other?
Phone # (secondary)
Your answer
Cell or other?
Email *
Your answer
Age *
Your answer
Gender
Your answer
Height *
Your answer
Weight *
Your answer
Date of Birth
MM
/
DD
/
YYYY
Occupation:
Your answer
How many hours per week do you currently work?:
Your answer
Enjoy your work?:
Describe your work situation, does it require sitting often, staring at a computer, being in-doors, away from windows, being around a high amount of wifi or other electrical devices, chemicals, using antibacterials often? Please explain:
Your answer
Primary Sources of Stress?
Your answer
Do you take any particular steps to improve stress management? :
Your answer
Have supportive relationships in your pursuit of your health/performance goals?:
Have areas in your life where you find passion, purpose, meaning?
#1 health concern or performance goal (Please list them in order of importance to you): *
Your answer
#2 health concern or performance goal:
Your answer
#3 health concern or performance goal:
Your answer
On a scale of 1 - 10, how committed are you to doing whatever it takes to achieve your goal(s)?
Not at all
I'll do whatever it takes!
How much time are you willing/able to dedicate toward achieving your goal(s) per day/week?
Your answer
What do you foresee being your primary obstacle to achieving your goal(s)?
Your answer
Do you have any other particular issues that you are concerned about, whether they seem important now or not?:
Your answer
Have you recently worked with any other practitioners/trainers/coaches on these goals? If so, who?
Your answer
Are you currently being treated for any medical conditions?:
Your answer
Have you been diagnosed with any other conditions as an adult?: *
Your answer
Do you feel pain in your chest when you perform physical activity? *
In the past month, have you had chest pain when you were not performing any physical activity? *
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? * *
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 a change in your physical activity?
Do you know of any other reason why you should not engage in, or be cautious during physical activity? *
Describe any current acute or chronic injuries or problem/pain areas effecting your performance?
Your answer
Do you exercise?:
What are your current training goals (if different than top 3 health goals above):
Your answer
What does a typical week of training/exercise look like? :
Your answer
How much do you move outside of formal exercise? :
Your answer
Describe how many/which days per week you can train, and at what times of day:
Your answer
List any Personal Records (PRs) or benchmarks in exercise/training that you have kept track of (Dead Lift? Squat? Press? Push-up? Pull-up? 400m time? 1 mile time? 5k time? Marathon time? etc)
Your answer
Describe any specific pre- during -post workout/event nutrition/fueling habits you utilize?
Your answer
Shoes you usually exercise in?:
Your answer
Shoes you usually work in?:
Your answer
other shoes often worn?:
Your answer
Any additional orthopedics, inserts, etc?:
Your answer
Do you sleep well? :
How long do you sleep for on average?
Your answer
Do you take any particular steps to improve your sleep? :
Your answer
List items plugged-in and active wireless devices in bedroom at night:
Your answer
Spend time outside? If so, how much time/ how often on average?
Your answer
Time spent sitting per day?:
Your answer
What medications and supplements do you currently take?:
Your answer
What other medications and supplements have you regularly taken over the last year?:
Your answer
List any/all sensitivities and/or allergies:
Your answer
What does a typical day of food/drink look like? :
Your answer
Do you take a particular approach to your diet (types of diets, foods you avoid, etc)? :
Your answer
If so, why? :
Your answer
Do you eat out often?:
What percentage of your foods are organic, grown without chemicals, grass-fed or free-range?:
Your answer
What percentage of your food is bought fresh/unprocessed (i.e. unprocessed produce, unprocessed meats)?:
Your answer
Use a microwave?
Use alcoholic beverages?:
If so, how often/what type & quantity?:
Your answer
Do you use tobacco? If yes, what form and how often:
Your answer
Any history of addiction?:
Any other drug use?:
List all household cleaners present in/around home/car (kitchen, bathroom, windows, etc) including brand:
Your answer
List all laundry cleaning/softener products used, including brands:
Your answer
List all body/beauty care products used, including brands and product name:
Your answer
Any and all known mold locations in home, however small:
Your answer
Do you use any devices/ways of protecting yourself from electromagnetic frequencies, radiation, etc?:
Your answer
Additional Information:
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