BALLISTIC STRENGTH NANAIMO
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!
Indicates required field
How did you hear about us?
If Other please specify:
Emergency Phone Number
What is your Date of Birth?
Describe your current activity level
Sedentary (little or no exercise; desk job)
Lightly Active (light exercise/sports 1-3 hours/week)
Moderately Active (moderate exercise/sports 3-5 hours/week)
Very Active (hard exercise/sports 6-7 hours/week)
Extremely Active (hard daily exercise/sports and physical job or 2x day training)
Have you followed a weight training program before (minimum of 2 consecutive months at 2-3x per week)? Describe.
What is your confidence level with weight training?
Activity history (e.g. high school or college sports; anything before 2 years ago)
Current Activities (include Frequency, Intensity, Duration, and Type)
Choose Any That Apply to you
Low Back Pain
Chronic Joint Pain
Type 1 Diabetes
Type 2 Diabetes
Neck Pain or Tension
High Blood Pressure
Asthma, Bronchitis, etc.
Low Blood Pressure
Other Congenital Heart Condition
Have you had orthopedic surgery? Please Describe.
Are you currently recovering from an injury, or recently recovered from an injury?
Do you have a tendency to continue to exercise despite experiencing symptoms of pain in a bodypart that you are using?
ANYTHING ELSE THAT YOU WOULD LIKE TO MENTION?
TRAINING GOALS & EXPECTATIONS
I am contacting you because:
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)
What best describes why you choose to exercise or pursue an exercise program?
I am driven by my inner beast!
I enjoy being active with others, meeting new people
I have dysfunctions that I need to correct
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.)
Please list and describe what you ENJOY and/or DISLIKE about exercise and/or weight training.
What 5 of these goals are most important to you?
Put on size
Be more active
Strengthen my heart
Reduce blood pressure
Improve body shape and composition
Learn to lift weights
Gain more gym confidence
Learn new skills
Find something new, fun, sustainable
Improve eating habits
Which goal do you want to achieve first?
What needs to be done to achieve this goal?
Are there personal barriers keeping you from fulfilling this goal?
Set a deadline for this goal
Less than 1 month
6 months to 1 year
How did you choose this timeline?
If any of your 5 goals include: "lose weight", "put on size", "improve body shape and composition", or "improve eating habits", then you must fill out this section and do so honestly. Anything less indicates that these goals are not actually important to you.
Do you feel like your eating habits are negatively affecting how you look, feel or perform?
If "YES", explain. If "MAYBE", why didn't you answer "YES"?
If you are taking any nutritional supplements/Vitamins, etc., please list them here. Why do you take them? Who recommended them?
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
If you are pursuing training services through us, please list your availability here to the best of your ability.
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.
GRIP STRENGTH COMPETITION
NANAIMO KETTLEBELL CLUB
Closer Than You Think!
11 Giggleswick Pl
Indicates required field
I agree to receiving marketing and promotional materials
Subscribe to Newsletter