New Client Forms | Studio Da Capo

top of page

148badab8ed6-StudioDaCapo_Logomark_Color (1).png

Home
Offerings
About
Contact
More

Use tab to navigate through the menu items.

Client Intake Form

First and Last Name *

Email *

Phone Number *

What is/are your goal(s) for our work together? *

Why is this goal important to you? *

Are you ready to commit to the Success Path (working out with me twice weekly, doing your 10-minute home work out twice weekly, setting and achieving goals toward simple but effective lifestyle changes) laid out for you in order to achieve your goals? *

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke? *

Yes

Have you ever experienced unexplained pains or discomfort in your chest at rest or during physical activity/exercise? *

Yes

Do you ever feel faint, dizzy, or lose balance during physical activity/exercise? *

Yes

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *

Yes

If you have diabetes (type 1 or 2), have you had trouble controlling your blood sugar (glucose) in the last 3 months? *

Yes

Do you have any other serious health conditions that may require special consideration for you to exercise? *

Yes

Describe your current physical activity/exercise level in a typical week. What are you doing and for how long? *

Is there anything else you would like to share with me? *

I declare that the info I’ve provided is accurate & complete.

I agree that I have read Laibility Waiver and fully understand its contents and voluntarily agree to be bound to all of its terms.Liability Wavier.

I have read and fully understand and agree to Studio Da Capo'sTerms and Conditions.

Your Signature

Select a date

Thanks for submitting!