Intake Form

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- Intake Form

What We Do
Our Trainers
Testimonials
Shop
Contact Us
- Intake Form

Peterborough, New Hampshire

Assessment – please complete this intake form for War Room Athletics, Peterborough NH. Upon completion of form we’ll contact you to schedule a time to come in.

Personal Information

Full Name *

Email Address *

Phone Number *

Mailing Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Height *

Weight *

Birth Date *

MaleFemale

Emergency Contact *

Emergency Contact Phone *

Physicians Name *

Physicians Phone *

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

If you have answered “Yes” to one or more of the below questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *YesNo

Do you feel pain in your chest when you perform physical activity? *YesNo

In the past month, have you had chest pain when you were not performing any physical activity? *YesNo

Do you lose your balance because of dizziness or do you ever lose consciousness? *YesNo

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *YesNo

Do you know of any other reason why you should not engage in physical activity? *YesNo

GENERAL & MEDICAL QUESTIONNAIRE

Occupational Questions

What is your current occupation? *

Does your occupation require extended periods of sitting? *YesNo

Does your occupation require extended periods of repetitive movements? (If yes, please explain.) *YesNo

If "yes" please explain

Does your occupation require you to wear shoes with a heel (dress shoes)? *YesNo

Does your occupation cause you anxiety (mental stress)? *YesNo

Recreational Questions

Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.) *

Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.) *

Medical Questions

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.) *

Have you ever had any surgeries? (If yes, please explain.) *

Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.) *

Are you currently taking any medication? (If yes, please list.) *

Any allergies? *

CLIENTS TERMS & CONDITIONS – WAIVER & RELEASE

Acknowledgment of Risks, Injury & Obligations

I acknowledge that the activity I am to undertake is a dangerous activity and that by participating in it I am exposed to certain risks. I acknowledge and understand that whilst participating in such activity: I may be injured, physically or mentally, or may die; My personal property may be lost or damaged; Other persons participating in such activity may cause me injury or may damage my property I may cause injury to other persons or damage their property The conditions in which the activity is conducted may vary without warning I may be injured or die or suffer damage to my property as a result of the negligence or breach of contract of War Room Athletics LLC. There may be no or inadequate facilities for treatment or transport of me if I am injured I assume the risk of and responsibility for any injury, death or property damage resulting from my participation in the activity.

Release and Indemnity

I participate in the activity at my sole risk and responsibility. I release, indemnify and hold harmless War Room Athletics LLC, its servants and agents, from and against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of or arising out of any injury, loss, damage or death caused to me or my property whether by negligence, breach of contract or in any way whatsoever.

Administration

Appropriate covered footwear & a shirt must be worn at all times while in the gym facility. Memberships are not refundable or transferable. All weights and equipment must be put back after use. Photo ID cards (ie student card or drivers license) must be carried and shown upon request. Shared gym access with a non-member will result in forfeiture of membership effective immediately. Each member must respect other gym users and behave in an appropriate manner at all times. War Room Athletics LLC Staff reserves the right to rescind the rights of members not complying with the terms and conditions of the membership. If any equipment, gear or property of War Room Athletics LLC is damaged and/or destroyed by my own doing or of family or friends that are with me, I am required to pay for the repair and/or the replacement for that item or property that was damaged or destroyed Anyone under the age of 16 must be accompanied by an adult at all times within the gym. If purchasing personal training sessions, I understand that the sessions and/classes are non-refundable and nontransferable.

By typing my full name below I agree to the above terms *