Ballistic Strength Intake Form

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.
This intake form is to help us get a good grasp on your physical attributes, past and recent activity and training experience, motivations, 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!

Describe your job / lifestyle *

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 *

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

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? *

What best describes why you choose to exercise or pursue an exercise program? *

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: *

I am interested in trying kettlebells I am looking for personal training sessions I want to try your Healthy Habits coaching services I want to try your Performance coaching services I want to try your Physique / Body Recomposition coaching services I'd like a home exercise program I am recovering from an injury and need help getting back into safe physical activity

If you are taking any medicinal drugs, nutritional supplements/Vitamins, etc., please list them here. Why do you take them? Who recommended them? *

If so, If you have ever struggled with weight management, eating habits, or maintaining a positive mental state, then perhaps you might consider my personalized coaching program where I attempt help you take stock of your Strengths, weaknesses, bio-psycho-social health, and to develop the necessary skills to empower you to pursue your personal goals confidently. If so, please click on the image to visit my Personalized Coaching webpage, where you can also find a link to the nutrition intake form.

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. *

I AGREE

INTAKE FORM

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