First Name *

Last Name *

E-Mail *

Phone *

Date Of Birth *

What are your overall health & fitness goals?

Improve overall health
Increase strength
Improve athletic performance
Increase muscle mass
Injury/condition prevention
Increase flexibility/mobility
Injury/condition rehabilitation
Decrease fat mass

What obstacles may have to be navigated on your journey toward your goals?

Injury/condition
Knowledge
Performance
Nutrition
Occupation
Time
Discipline/motivate
Social life
Finances

What exercise style(s) do you enjoy most?

Resistance: general
Resistance: HIIT
Calisthenics
Run: distance
Run: sprint/agility
Cycling
Sport(s)
Swim
Yoga

Which tier of Vella Health Train | Rehab programming are you currently interested in?

Tier I (1 sess./mn)
Tier II (1 sess./wk)
Tier III (2 sess./wk)

Has your physician informed you on having a heart condition or high blood pressure? *

Do you experience chest pain at rest or while exerting yourself? *

Have you lost your balance because of dizziness or have lost consciousness in the last 12 months? *

Have you had a bone, joint or soft tissue injury that becomes worse with or inhibits you from physical activity in the last 12 months? *

Have you ever been diagnosed with a chronic medical condition? *

Are you currently taking prescribed medication for a chronic medical condition? *

Has your physician informed you to only perform medically supervised physical activity? *

I acknowledge Liability Waiver *

I acknowledge Service Agreement *

I, the undersigned, have read, understood to my full satisfaction, and completed this BASELINE questionnaire and am agreeable to both the Liability Waiver and Service Agreement. I acknowledge that this physical activity clearance, release of liability, and service agreement are valid for no more than 12 months from the submission date and becomes invalid if my condition changes. I acknowledge that a copy of this form may be retained for recordkeeping. In these instances, it will maintain the confidentiality of the same, complying with applicable law. *

Clear

Signature

Baseline - Submitted.

Thank you for submitting your Baseline with Vella Health.

Baseline - Submitted.

Thank you for submitting your Baseline with Vella Health.

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