Transformation Challenge Intake Form

CLIENT INTAKE FORM

THIS FORM IS INTENDED FOR TRANSFORMATION CHALLENGE PARTICIPANTS ONLY.

Fall 2022 Transformation Challenge Intake Form

Personal Contact Information

Name(Required)

First Last

Phone(Required)

Do you give permission to PF4U Coaches to call or text you? Y/N(Required)

Yes

Email(Required)

This is where our coaches will be sending your program information! Please double-check your spelling!

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How did you hear about the Transformation Challenge?(Required)

If you were referred, please tell us from who!

We would love to thank them but will not include your personal information. If a specific coach has referred you, please include their name here.

Personal Health Information

Age(Required)

Please enter a number from 12 to 99.

Birthdate(Required)

Height(Required)

In feet and inches

Current Weight(Required)

Please enter a number from 75 to 999.

In pounds

Body Fat Percentage

Please enter a number from 1 to 100.

Only include if results are representative of your current physique. If are unsure of this value and within driving distance to our headquarters- consider trying our Body Composition Machine!

Do you own a smart watch?

If so, what kind?

If you do own a smart watch, what is your estimated calorie burn?

This is your daily MOVE amount on an Apple Watch or Daily Calorie Burn on FitBit

Are you within 5 days of your last menstrual period?(Required)

Are you pregnant?(Required)

Are you breastfeeding?(Required)

Do you smoke?(Required)

Do you drink alcohol regularly?(Required)

If so, how frequently?

Have you been diagnosed with any chronic medical conditions?

If so, please explain.

Have you been prescribed any medications which you are to take on a regular basis?

If so, please explain.

How many hours of sleep do you receive PER night on average?(Required)

Please enter a number from 1 to 23.

What are your favourite activities/hobbies?(Required)

On a scale of 1-5, how do you rate your health as a priority?(Required)

1= low priority, 5= top priority

On a scale of 1-5, how does your support system rate their health as a priority?(Required)

1= low priority, 5= top priority

What is your current occupation?(Required)

How many days/week do you typically work?(Required)

Please enter a number from 1 to 7.

How many hours/week do you typically work?(Required)

Please enter a number from 1 to 99.

Does your occupation require you to travel often?(Required)

Training Information

Do you have a preferred way to execute your physical activity?(Required)

Resistance Training, Power Lifting, Yoga, Hiking, Endurance Training, Cardio, Group Exercise Classes, etc.

On a scale of 1-5, how do you rate your current fitness level?(Required)

1= worst it’s ever been, 5= best it has ever been

Nutrition Information

Have you ever tracked your food intake before?(Required)

How familiar are you with “macros” and “macro counting”?(Required)

1= poor, 5= excellent

Additional Information

Would you prefer the group meetings to be in person or virtual?

In Person

Virtual

No Preference

If you select in person, you must be able to commute to Lethbridge for the meetings.

Do you have children?

Yes - Young Children (0-10 years old)

Yes - Older Children (11 years - adult aged)

What is your level of interest in the Personal Development aspect of the Transformation Challenge?

Very Interested

Open to learning more

Not Interested at all

If you are interested in Personal Development, which of the following topics interests you the most?

Habit formation, identity shifts, becoming a leader, creating a compelling vision, and cultivating courage and trust

Learning about how fat loss actually works, the female hormone component to weight loss and how to improve your mindset about dieting.

If you were to set 1-2 health and wellness goals that you hope to achieve in the next year, what would they be?(Required)

Please describe how your ideal coach would best support you in achieving these goals.(Required)

Do you currently have (or have had within the past 12 months) high thyroid, peri-menopausal symptoms, a recent hysterectomy or have you recently went off of birth control?(Required)

Have you been diagnosed with any of the following medical conditions: Hypertension, Diabetes, Cirrhosis or Diverticulitis?

PAR-Q

Please Note: If you have answered YES to any of the PAR-Q question below, it is imperative that Perfectfit4u receives a doctors note (uploaded below) before constructing your training programming.

Has your doctor ever said that you have a heart condition or high blood pressure?(Required)

Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?(Required)

Do you lose balance because of dizziness or have you lost consciousness in the last 12 years? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).(Required)

Have you ever been diagnosed with another chronic medical condition?(Required)

If so, please describe.

Are you currently taking prescribed medication for a chronic medical condition?(Required)

If so, please describe.

If yes, please describe:

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.(Required)

Has your doctor ever said that your should only do medically supervised physical activity?(Required)

Doctors Note Upload

Max. file size: 300 MB.

This upload is only required if you have answered YES to any of the above PAR-Q questions.

Enter Today's Date(Required)

This field is for validation purposes and should be left unchanged.