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
MOTIVATION/DISCIPLINE
SOCIAL LIFE
FINANCES

WHAT EXERCISE STYLE(S) DO YOU ENJOY MOST?

RESISTANCE - GENERAL
RESISTANCE - HIIT
CALISTHENICS
RUNNING - DISTANCE
RUNNING - SPRINT/AGILITY
CYCLING
SPORT(S)
SWIM
YOGA

WHICH TIER OF VELLA HEALTH TRAIN | REHAB PROGRAMMING ARE YOU CURRENTLY INTERESTED IN?

TIER I (1 SESSION/MN)
TIER II (1 SESSION/WK)
TIER III (2 SESSIONS/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, THE UNDERSIGNED, HAVE READ, UNDERSTOOD TO MY FULL SATISFACTION, AND COMPLETED THIS BASELINE QUESTIONNAIRE AND SUBSEQUENT LIABILITY WAIVER. I ACKNOWLEDGE THAT THIS PHYSICAL ACTIVITY CLEARANCE AND RELEASE OF LIABILITY ARE VALID FOR NO MORE THAN 12 MONTHS FROM THE UNDERSIGNED 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 & DATE

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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