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Form Intention Studios

Wuji Xiao Yao Kung Fu Academy

Texada Island BC

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Form Intention Studios-Client Intake Form

Date

Year

Month

Day

First name*

Last name*

Email

Phone*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Emergency Contact and Relationship*

Phone*

Physical Activity

1. In the last 12 months, how often have you been active in some sort of exercise?

3 to 4 times a week

1 to 2 times a week

1 to 2 times as month

not at all (may be due to pregnancy or ill health)

What sports or activity has worked for you in the past?

What type of exercise do you enjoy and where do you go to exercise?

What form of sport or exercise do you dislike?

Occupation/Leisure

What is your present occupation?

Does your occupation involve much physical activity? Ie. Lifting, walking?

What exercise or hobbies do you like to do in your spare time?

Stress

Rate yourself on a scale of 1-10, 1 being the calmest, 10 being suffering badly

1

2

3

4

5

6

7

8

9

10

What situations make you feel stressed?

How do you relax?

Diet

Do you think you eat healthy?

Do you eat breakfast?

Do you snack between meals? And if so what do you have?

Do you think you eat more then you need?

How many calories do you eat in a day?

How many liters of water do you drink in a day?

Weight

Do you consider yourself over weight?

If yes, how much would you like to lose?

Is the rate at which you lose weight important to you?

Fitness

Rate yourself on a scale of 1 to 10 as to how fit you think you are, 1 being least fit, 10 being most fit. Click the number that most applies.

1

2

3

4

5

6

7

8

9

10

How good is your stamina? 1 being no stamina, 10 being high stamina.

1

2

3

4

5

6

7

8

9

10

How strong do you think you are?

1

2

3

4

5

6

7

8

9

10

How flexible do you think you are?

1

2

3

4

5

6

7

8

9

10

How coordinated do you think you are

1

2

3

4

5

6

7

8

9

10

How much time will you have to exercise?

Minutes per day

Days per week

Goals

What do you exercise to do for you in the next:

1 month

3 Months

1 Year

Rate you goals in undertaking exercise

Extremely Important

Quite Important

Not Very Important

Rate, in your view, the following in importance 1-9. 1 being most important, 9 being the least

a. Improve overall health

b. Improve fitness

c. Reshape or tone the body

d. Improve performance for a sport

e. Improve moods and stress levels

f. Improve flexibility

g. Increase strength

h. Increase energy levels

i. Enjoyment

Name types of music and/or artists you like to listen to:

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Phone:778 998 0596
Email:Formintentionstudios@gmail.com

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Email*

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