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Goals and Intake Form
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Goals/Intake
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Intake Form Completed
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Who Conducted Intaked?
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Goals
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Time Frame
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Past Experiences
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Program Expectations
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Will He/She Be Training at Stark?
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If No, Where Will He/She Be Training?
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If Yes, What Type of Training Sessions?
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Weight Training Sessions Per Week
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Cardio Requirements?
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Additional Workouts
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Comments
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Current Ortho Concerns
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Past Injuries
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Family History
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Lifestyle
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Work/Stress
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Occupation
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Category of Person
• • •
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Work - Hrs/Week
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Is Your Work Stressful?
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Work - Activity Level
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Current Stress Levels
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Primary Source of Stress
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Work Stress
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Personal/Other Stress
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Sleep/Energy
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Sleep/Wake Times
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Average Hours/Night
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Do You Wake Up Regularly During the Night
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Comments:
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Time to Fall Asleep
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Pre-Bedtime Routine
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Morning Energy
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Afternoon Energy/Drops
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Restorative Activities
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Food/Digestion
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Typical Food Day
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Weekends
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Cravings
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Alcohol Consumption
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Digestive Issues
• • •
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Comments
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Known Food Allergies/Sensitivites
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Pooping Frequency
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Seasonal Allergies
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Allergy Symptoms
• • •
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Dry Skin
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Acne
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Meds/Supps
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Medications
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Birth Control
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Pain Killers/NSAIDS
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Most Recent Antibiotics
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Supplements
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Openness to Supplement Suggestions
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Water Intake
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Trace Minerals
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Body Metrics
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Cardiovascular
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HRV
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Resting HR
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Lying BP
/
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Lying to Standing BP
/
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Oximeter
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Structural
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Leg Length Discrepancy
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Pec Major
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Pec Minor
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Comments
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Lower Ab Test
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Prone Knee Flexion
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Thomas Test - Left
• • •
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Thomas Test - Right
• • •
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Standing Forward Head
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First Rib Angle
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Pelvic Tilt - Right
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Pelvic Tilt - Left
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C7 - T1
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T12 - L1
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L5 - S1
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Beighton Score
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Comments
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Body Comp
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Neck
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Right Arm
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Chest
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Waist
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Hips
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Right Thigh
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Right Calf
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InBody
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Before Pics (Fron, Side, Back)
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FMS
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Deep Squat
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Raw Score
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Comments
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Final Score
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Hurdle Step
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Left Raw Score
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Comments
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Right Raw Score
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Comments
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Final Score
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Lunge
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Left Raw Score
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Comments
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Right Raw Score
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Comments
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Final Score
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Shoulder Mobility
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Left Raw Score
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Comments
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Right Raw Score
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Comments
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Measure
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Left Best
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Right Best
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Right Side Clearing Test
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Comments
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Left Side Clearing Test
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Comments
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Final Score
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Straight-Leg Raise
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Left Raw Score
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Comments
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Right Raw Score
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Comments
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Final Score
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Trunk Stability Push-Up
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Raw Score
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Comments
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Clearing Test
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Comments
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Final Score
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Rotary Stability
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Left Raw Score
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Comments
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Right Raw Score
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Comments
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Clearing Test
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Comments
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Final Score
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Total Score
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Aerobic Test
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Pulse 1
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Pulse 2
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Pulse 3
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Time Completed (Sec)
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Score
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Speed (RPM)
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Max HR
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Comments
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