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INTAKE FORM
This intake form is to help us get a good grasp on your motivations, past and recent activity and training experience, and your expectations from participating in our programs. It is a general intake form, so though you may not feel as though all these questions are relevant to what you're looking for (e.g. private training, VS. classes VS. Coaching), please fill out the form in its entirety. Thanks!
Contact Information
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Indicates required field
Name
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First
Last
Email
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Choose One
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Male
Female
How did you hear about us?
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Internet Search
Advertisement
Friend
Other
If Other please specify:
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OCCUPATION
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Emergency Contact
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Doctor
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Emergency Phone Number
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Doctor's Number
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Personal Information
Height
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Weight
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What is your Date of Birth?
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Describe your job / lifestyle
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Sedentary Job (e.g. call center, bank clerk)
Busy Job (e.g. Busing tables, line cook)
Physical Job (e.g. labourer, mover)
Retired but active (e.g. chores, gardening, maintenance)
Retired but inactive (e.g. don't leave house much, sit mostly, card games)
Describe your current exercise level
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little or no exercise
light exercise or sports 1-3 hours/week
moderate exercise or sports 3-5 hours/week
hard exercise or sports 5-7 hours/week
hard daily exercise or sports 2x day
Have you followed a weight training program before (minimum of 4 weeks at 2-3 sessions per week)? Describe.
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Describe your confidence level with weight training?
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Have you worked with a trainer or coach before?
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Have you had kettlebell instruction before?
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Activity history (e.g. high school or college sports; anything before 2 years ago)
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Current Activities (include Frequency, Intensity, Duration, and Type)
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Medical History
Choose Any That Apply to you
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Low Back Pain
Chronic Joint Pain
Type 1 Diabetes
Type 2 Diabetes
Headaches
Neck Pain or Tension
High Blood Pressure
Asthma, Bronchitis, etc.
Low Blood Pressure
Fibromyalgia
Multiple Sclerosis
Arthritis
Other Congenital Heart Condition
Muscle Weakness
Have you had orthopedic surgery? Please Describe.
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Are you currently recovering from an injury, or recently recovered from an injury?
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Do you have trouble telling the difference between discomfort that is part of the process of exercise, versus pain or discomfort that indicates something is wrong?
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ANYTHING ELSE THAT YOU WOULD LIKE TO MENTION?
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TRAINING GOALS & EXPECTATIONS
What best describes why you choose to exercise or pursue an exercise program?
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I need to move and be physical
I enjoy being active with others, meeting new people
I have dysfunctions that I need to correct
Weight management
I have personal goals to achieve (e.g. learn how to snatch, lose 15 lbs, deadlift 200 lbs, etc.)
I have a deadline to meet (e.g. physique competition, sport recruitment camp, etc.)
I am contacting you because:
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I'd like a home exercise program
I am looking for personal training sessions
I want your help and expertise to change my body composition (i.e. nutritional coaching)
I don't know what to do about my fitness - HELP!
I am interested in trying kettlebells
I am recovering from an injury and need help getting back into safe physical activity
I just want technical coaching
Some other reason (see below)
Explain
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Please list and describe what you ENJOY and/or DISLIKE about exercise and/or weight training.
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Do you find it easy or difficult to exercise regularly (e.g. 30 min, 4-5x per week)
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What 5 of these goals are most important to you?
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Lose weight
Put on size
Be more active
Strengthen my heart
Reduce blood pressure
Improve body shape and composition
Learn to lift weights
Develop confidence in myself
Get stronger
Learn new skills
Find something new, fun, sustainable
Improve eating habits
Which goal do you want to achieve first?
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What is a skill you would need to have to achieve this goal?
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What would be a routine / habit necessary for building this skill?
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What is one daily action, so easy you can't say no to, that you can do right now to start building the habit?
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Identify some potential future (or current) obstacles to your goal(s).
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Goals are dreams with deadlines: set one.
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About 1 month
2-3 months
6 months to 1 year
2-3 years
How do you know this timeline is realistic?
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The right fit
The Nanaimo Kettlebell Club promotes health & fitness through community - i.e. making friends, taking ownership, setting goals, being accountable. We do not promote quick fixes, only self-determination. We want to give you the tools to reach long-term success.
Are you just looking for your new sweat factory, or are you looking for something more?
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Nutritional Considerations
If any of your 5 goals include: "lose weight", "put on size", "improve body shape and composition", or "improve eating habits", or even "Develop Confidence in Myself", and you have not taken positive action to adjust your food behaviours or environment, then you should consider personalized coaching to help you get the ball rolling.
Inquire about personalized coaching with Solly
Do you feel like your eating habits are negatively affecting how you look, feel or perform?
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Yes
No
Maybe
If "YES", explain. If "MAYBE", why didn't you answer "YES"?
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If you are taking any medicinal drugs, nutritional supplements/Vitamins, etc., please list them here. Why do you take them? Who recommended them?
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This is important for several reasons: negative side effects that may endanger you or others during class; some supplement ingredients are on the WADA banned list; some supplements are a waste of money and I can tell you which ones and why
I assure that the information I have provided to be accurate, and that I provide this information freely to Ballistic Strength Nanaimo (the company) so that the company may provide the best service(s) possible based on that information. I do not give the company permission to sell, trade, misuse, manipulate, or release my personal information publicly or privately in digital format or otherwise without my expressed written consent.
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I AGREE
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