Intake & Assessment Form

WELCOME TO YOUR NEXT STEP!

Now that you have made a committment to begin coaching, we are going to ask you form some information so we can connect you with the Coach Me Strong coach best suited for you individual needs.

This information is confidential and is protected and encrypted according to HIPAA standards. Only the Coach Me Strong management team and coaches have access to this information. You can expect us to contact you within 48 hours to review your information, talk through any additional concerns, then recommend one or more coaches. You are then welcome to contact each of our coaches prior to making a final decision on who will be your new coach.

Please contact us anytime with any questions.

Ready for step two? LET’S GET GOING!

"*" indicates required fields

GENERAL INFORMATION

Name*

First Last

Today's Date*

MM slash DD slash YYYY

Email*

Enter Email Confirm Email

Phone*

Address*

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

Date of Birth*

MM slash DD slash YYYY

Gender*

Male

Female

Height*

Weight*

Emergency Contact*

Emergency Contact's Relationship*

Emergency Contact's Phone*

Are you currently employed?*

Yes, full time

Yes, part time

Employer

Is your job active or inactive? Please describe:

Is your job stressful? Please describe:

MEDICAL HISTORY

When was your last physical exam?

MM slash DD slash YYYY

List any medications you are taking:*

Do you have (or have you had) any of the following. If you check any item, please explain below.

Heart attack

Chest discomfort

Elevated cholesterol (>200 mg/dl)

Elevated blood pressure (>140/>90 mm Hg)

Heart murmurs, rapid heartbeat, arrhythmia

Abnormal exercise EKG

Cigarette smoker

Overweight

Unusual shortness of breath

Rheumatic fever

Allergies

Peripheral vascular disease

Parkinson's Disease

Essential Tremor

ALS

Huntington's Disease

Diabetes

Stroke

Tramatic Brain Injury

Lightheadedness or fainting

Pulmonary disease (asthma, bronchitis, emphysema)

Recent hospitalization or illness

If you checked any of the above items, please explain:

Do you have (or have you had) any of the following. If you check any item, please explain below.

Surgery

Arthritis

Back/neck pain

Knee problems

Hip problems

Ankle swelling

Hand/wrist problems

Shoulder problems

Foot/ankle problems

Osteoporosis

Circulatory Problems

Kidney problems

Seizures or epilepsy

Pregnancy

Family members with history of heart disease, high blood pressure, or stroke

Past injuries

Current injuries

If you checked any of the above items, please explain:

Any other medical issues?

Please tell us a little about your exercise routines and history:

How many days each week to you exercise?*

For how long each day?*

Does your current exercise routine include (please check all that apply):

Walking

Running

Hiking

Stationary bike

Road or mountain bike

Swimming

Strength training in a gym

Strength training at home

Core and/or abdominal exercises

Wall or chair supported exercises

Stretching

Yoga

Pilates

Boxing

Group bootcamps

High Intensity Interval Training (HIT)

Other sports or exercises?

Do you have a current gym membership?

Yes

If yes, where?

Please list all the exercise equipment you have at home:*

Have you ever worked with:

An fitness coach?

A personal trainer?

A physical therapist?

An exercise physiologist?

If you checked any of the above items, please describe:

What is your history with exercise and sports? High School, college, as an adult, etc.*

Do you have any other information that will help us?

Coach Me Strong General Release of Liability and Covenant Not to Sue

1. In consideration of permitting me to participate in coached exercise and/or training programs, I HEREBY acknowledge that physical exercise and physical training and involves the risk of serious injury and/or death and/or property damage. I agree to the above paragraph.*

2. I HEREBY RELEASE, WAIVE, AND DISCHARGE Coach Me Strong and its parent company, UTD Scuba Diving, LLC, and any of its owners, officers, instructors, coaches, trainers, agents, contractors, or employees (the Releasees) FROM ALL LIABILITY TO MYSELF, my personal representatives, assigns, heirs, and next of kin FOR ANY AND ALL LOSS OR DAMAGE, AND ANY CLAIM OR DEMANDS THEREFOR ON ACCOUNT OF INJURY TO MY PERSON OR PROPERTY OR RESULTING IN MY DEATH, NOW AND FOREVER, ARISING OUT OF OR RELATED TO MY PARTICIPATION IN EXERCISE COACHING OR TRAINING OR ANY RELATED ACTIVITIES, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I agree to the above paragraph.*

3. I HEREBY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE, now and forever, arising out of OR RELATED TO MY PARTICIPATION IN EXERCISE COACHING OR TRAINING OR ANY RELATED ACTIVITIES, whether foreseen or unforeseen and whether caused by the negligence of the Releasees or otherwise. I agree to the above paragraph.*

4. I HEREBY agree to INDEMNIFY and SAVE and HOLD HARMLESS the Releasees from any loss, liability, damage or cost any of them may incur, now and forever, arising out of OR RELATED TO MY PARTICIPATION IN EXERCISE COACHING OR TRAINING OR ANY RELATED ACTIVITIES, whether caused by the negligence of the Releasees or otherwise.  I agree to the above paragraph.*

5. I HEREBY acknowledge that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES and agree that this agreement and release extends to all acts of negligence by Releasees. I agree to the above paragraph.*

7. I HEREBY ACKNOWLEDGE that the Release included in this agreement is intended to be as broad and inclusive as permitted by the laws of the Province or State in which the activities are conducted and that if any portion of this agreement and release is held invalid, the balance shall continue in full legal force and effect. I agree to the above paragraph.*

8. I HEREBY ACKNOWLEDGE I have read this agreement, fully understand its terms, understand that I have given up substantial rights by signing it, am aware of its legal consequences, and have signed it freely and voluntarily without any inducement, assurance, or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. I understand that this agreement represents the entire agreement between the parties regarding the subject matter hereof and supersedes any prior or contemporaneous agreements. I understand that this agreement may not be orally modified and I am not relying on representations made by anyone other than those set forth in this agreement. I agree to the above paragraph.*

Consent*

By digitally submitting this document I accept its terms and conditions and I state that I am over 18 years of age. This form complies with HIPAA privacy and encryption parameters.

BY WAY OF MY VOLUNTARY DIGITAL SUBMISSION, I AGREE THAT I HAVE FULLY READ AND UNDERSTAND THIS DOCUMENT IN ITS ENTIRETY. I UNDERSTAND THAT THIS IS A LEGALLY BINDING CONTRACT NOT TO SUE AND I AGREE TO BE BOUND BY IT.*