Movement Intake FormThis form is to help me get to know about your movement story, your relationship with your body and what motivates you. Name * First Name Last Name Date Of Birth * MM DD YYYY Phone * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact First Name Last Name Emergency Contact Phone How did you hear about me> Referral Google Friend Instagram Facebook Marketing Flyer Are there any limitations, injuries (past or present) or medical accommodations you need, or would like to share with me about? If you have kids, tell me briefly about their birth(s) (Vaginal, C-Section) Did you experience any tearing? Are you currently breastfeeding? Do you feel that you get enough quality sleep currently? How much sleep do you usually get in a 24 hour period? Are you physically active at the moment? If so what do you most enjoy doing? Do you have a particular workout routine or schedule? What does a typical day like look for you? Are you working / not working / taking care of family? Are you more active or more sedentary during your day? Do you currently experience any pain or discomfort? If yes, please give details of where in the body, how long you have experienced this for and if there are any known aggravators and whether you receive treatment for this? Do you or have you ever experienced any pelvic floor symptoms ie prolapse, incontinence (fecal or urinary), pelvic pain or pain during sex? If yes please give details and any treatment or care received. * Do you have any physical goals? Do you have any lifestyle goals? Less stress, more energy, community, happiness, improved sleep etc. What do you do to nourish yourself? Do you use any techniques to manage stress currently? What does self care look like to you? What is your relationship to your body, and body image like? Is there anything about your relationship to your body that is important for me to know? Have you or are you currently experiencing depression, anxiety, post-traumatic disorder symptoms or any other mental health concerns you'd like to share with me? Have you ever worked with a personal trainer before? If yes what was your experience? What would you like to get out of attending these sessions? * What days and times can you attend? * Monday 9.30AM Strength & Conditioning Wednesday 9.30AM Strength & Conditioning Friday 6AM Strength & Conditioning Friday 9.30AM Strength & Mobility Is there anything else you'd like to share with me? Thank you so much, I look forward to getting to know you! Zoe
