Fuerza Performance Training | Client Intake Form

Welcome to Fuerza Performance Training. To build a completely customized, safe, and effective roadmap for you, please fill out this assessment as accurately and thoroughly as possible. All information is kept strictly confidential.

1. Personal Profile

First Name *

Last Name *

Preferred Pronouns

Email Address *

Phone Number *

Date of Birth *

Emergency Contact Name *

Emergency Contact Phone *

2. Health & Medical History

Has a doctor ever diagnosed you with, or do you currently experience, any of the following? (Check all that apply)

Heart condition or AFIB Chest pain during activity High blood pressure Dizziness or loss of balance Diabetes (Type 1 or 2) Asthma or respiratory issues Currently pregnant / recently postpartum Recent surgery (last 12 months)

Have you been cleared for rigorous physical activity by a medical professional? *

Yes, I have been cleared No / I have not seen a doctor Not sure / It has been a while

If you answered No or Not Sure, I may ask you to consult a physician before we begin depending on what your intake reveals.

Do you have any current or past bone, joint, or muscle injuries? (e.g. Rotator cuff, knee pain, lower back) *

Are you currently taking any prescription medications that affect your heart rate, blood pressure, or physical performance?

3. Lifestyle & Recovery

What is your current occupation/job? *

Average hours of sleep per night?

Daily Stress Level (1 = Low, 10 = Very High)

How would you describe your current nutrition?

4. Training History & Goals

How did you hear about me?

Describe your current exercise routine. *

What are your top 2 primary goals for the next 3-6 months? *

How many days per week can you realistically commit to training? *

Which days and times generally work best for you? Just your general availability, we'll lock in the exact schedule during your consultation.

What has been your biggest obstacle to fitness in the past?

Is there anything else you want me to know before we talk?

5. Acknowledgment I verify that the information provided above is accurate and true to the best of my knowledge. I understand that hiding medical conditions or injuries poses a severe risk to my safety during physical training.

Client Signature

Date

By submitting this form I consent to sharing this health information with Marco Carrillo-Muñoz, ACE-CPT for the purpose of building my personalized training program.

Fuerza Performance Training is not a medical provider. Programming and nutrition guidance are educational in nature and do not constitute medical advice. Individual results vary and are not guaranteed.