Intake Form Step 1 of 5 20% Personal InformationName First Last Email PhoneAddress Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What's your T-shirt size?*XSSMLXLXXLSocial Media & ContactWhere do you hang out on social media?* Facebook Instagram Twitter What is your social media account handle (name)?* What is the best mode of communication for you?* Cell Phone Email Social media direct message What time zone are you located in?* Eastern Central Mountain Pacific The Wolfpack will require 1:1 partner work. Do you feel comfortable working with another Wolfpack member?* Yes No What is your occupation? Please describe:* Does your job require you to travel?* Yes No How often do you have to travel? Please describe. How active are you on a daily basis? Very Active Moderately Active Slightly Active Sitting All Day What is your current stress level?*(1 – relaxed AF, 10 – stressed out of my mind)12345678910Please list your three biggest sources of stress?How many hours of sleep do you get on average per night?Please enter a number from 0 to 24.Do you smoke?* Yes No Do you drink alcohol?* Yes No How many drinks per week?What do you currently do for fitness?* Why are you joining The Wolfpack?* What are your goals for this program?What type of movement or workouts do you like to do?Realistically, how many days per week would you like to work out?*Please enter a number from 1 to 7.Realistically, how much time do you want to spend exercising during each session?* Do you have access to a gym and equipment such as barbells, kettlebells, dumbbells? Yes No What would an ideal training week look like for you?* Do you feel confident using a barbell?* Yes No Do you feel comfortable with compound movements (Squat, Deadlift, lunge)?* Yes No Untitled How can I best serve you when it comes to meeting your fitness goals?*Check all that apply. Increase muscle size Increase strength Design a more advanced strength and conditioning program Training for an event or race Reduce Stress Fun Motivation Learn Specific Kettlebell, Barbell, or other Lifting techniques Other You chose "Other". Please explain: When is the last time you consistently took dedicated time for yourself and your own health and fitness goals?* What has been the biggest barrier to starting or maintaining your fitness goals?* How important is it for you to achieve these goals?* How hard will it be for you to carve out time each week to achieve these goals?* On a scale of 1 – 10, how important do you rate health and fitness?*Please enter a number from 1 to 10.What are potential obstacles that could impede your progress towards accomplishing your goals?* Has your doctor ever said you have a heart condition?* Yes No Do you feel pain in your chest when you do physical activity?* Yes No Do you lose your balance because of dizziness or do you ever lose consciousness?* Yes No Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program*(i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc) Yes No Are you pregnant now or have given birth within the last six months?* Yes No Have you had a recent surgery?* Yes No Do you take any medications, either prescription or non-prescription, on a regular basis?* Yes No What is the medication for?* Do you know of any other reason why you should not do physical activity? Who do you live with?* What does your ideal day look like?*How would your best friend describe you?* If you had ALL the money in the world, what would you do with it?* Which best describes you?* Extrovert Introvert How do you recharge your battery?* What is your intention for this program?* How do you define Community? What does success look like to you in 6 months?* What is your commitment to yourself and to others in this group?* What is something you want me to know about you?* Please share one fun, special, or quirky fact about yourself.*
