Intake Form Step 1 of 5 20% Personal InformationName First Last Email PhoneAddress Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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?*FacebookInstagramTwitterWhat is your social media account handle (name)?*What is the best mode of communication for you?*Cell PhoneEmailSocial media direct messageWhat time zone are you located in?*EasternCentralMountainPacificThe Wolfpack will require 1:1 partner work. Do you feel comfortable working with another Wolfpack member?*YesNo What is your occupation? Please describe:*Does your job require you to travel?*YesNoHow often do you have to travel? Please describe.How active are you on a daily basis?Very ActiveModerately ActiveSlightly ActiveSitting All DayWhat 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?*YesNoDo you drink alcohol?*YesNoHow 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?YesNoWhat would an ideal training week look like for you?*Do you feel confident using a barbell?*YesNoDo you feel comfortable with compound movements (Squat, Deadlift, lunge)?*YesNo UntitledHow 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?*YesNoDo you feel pain in your chest when you do physical activity?*YesNoDo you lose your balance because of dizziness or do you ever lose consciousness?*YesNoDo 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)YesNoAre you pregnant now or have given birth within the last six months?*YesNoHave you had a recent surgery?*YesNoDo you take any medications, either prescription or non-prescription, on a regular basis?*YesNoWhat 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?*ExtrovertIntrovertHow 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.*
