Forms

Welcome! To ensure we have all the information needed to safely begin our work together, please review our Terms of Service & Privacy Policy and complete the three forms below. Your signature on these forms indicates your agreement to these policies. Please note each form requires its own ‘Submit’ click to be sent to our system. Also, if you walk away from the form prior to selecting “submit” your data may not save.

1. Client Agreement & Liability Waiver

Please fill out the details below and click Submit to complete Step 1.

Please enter your full name as it appears on your ID.
This field is required.
Please provide the name of someone we can contact in case of an emergency.
This field is required.
Enter a valid phone number for the emergency contact.
This field is required.
Please list any health conditions or injuries that may affect your participation.
This field is required.
I understand that Built for Life is not a medical provider and does not guarantee reimbursement from HSA, FSA, or insurance providers. I acknowledge that I am responsible for full payment and that the documentation provided is limited to a standard itemized receipt upon request.
This field is required.
I have read, understood, and agree to the <a href="https://builtforlifefit.com/privacy-policy/" target="_blank">Terms of Service & Privacy Policy</a> and the Liability Waiver & Hold Harmless Agreement.
This field is required.

2. Physical Activity Readiness Questionnaire (PAR-Q)

Complete the questionnaire and click Submit to proceed to the final step.

Enter your full name as it appears in your identification.
This field is required.
Provide your city and state for virtual sessions, or note 'Studio' for sessions in Manchester Center, VT.
This field is required.
This field is required.
Gender
Select your gender identity.
This field is required.
Do you have a history of heart problems?
Select yes or no based on your medical history.
This field is required.
This field is required.
Have you experienced chest pain during physical activity?
Select yes or no based on your experiences.
This field is required.
This field is required.
Do you ever feel faint or have severe dizziness during exercise?
Select yes or no based on your experiences.
This field is required.
This field is required.
Do you have a joint or bone problem that could be made worse by exercise?
Select yes or no based on your health conditions.
This field is required.
This field is required.
Have you ever been advised by a physician to not exercise?
Select yes or no based on your medical advice.
This field is required.
This field is required.
Do you take any medications for blood pressure or heart conditions?
Select yes or no.
This field is required.
Please describe any medical conditions.
If you have an injury or medical condition, have you received medical clearance from a doctor to participate in physical activity?
This field is required.
This field is required.
This field is required.
You must confirm that the details provided are accurate.
This field is required.

3. Lifestyle and Health History

This is the final form. Once you click Submit, your intake is complete!

Enter your full name as it appears on your health records.
This field is required.
Please enter your date of birth (MM/DD/YYYY).
This field is required.
Enter your height in feet/inches.
This field is required.
Enter your weight in pounds.
This field is required.
Enter your primary physician's name.
This field is required.
Enter your physician's phone number.
This field is required.
List the exercise activities you currently take part in (e.g., running, cycling).
This field is required.
How many days per week do you engage in at least 60 minutes of moderate-intensity exercise?
This field is required.
Following a Special Diet
Are you currently following a special diet?
This field is required.
This field is required.
Daily Intake Levels
Rate your daily intake of salt, sugar, and fat levels. <br>
This field is required.
Do you consume alcohol or caffeinated beverages? If yes, how much per week?
How do you manage your stress?
This field is required.
Smoking or Vaping
Do you smoke or vape?
What is your occupation?
This field is required.
Does your job/daily routine require sitting?
Does your job/daily routine require prolonged sitting?
This field is required.
How many hours do you sit during work each day?
Repetitive Movements
Does your job/doily routine require repetitive movements?
This field is required.
What type of footwear is required for your job? Alternatively, what type of footwear do you wear daily?
Do you participate in any recreational physical activities? Please provide examples.
Please list any hobbies you participate in.
Please list any musculoskeletal injuries you've had. (If you entered this information on the PAR-Q, please feel free to indicate "see PAR-Q.")
This field is required.
Please list any past surgeries you've had. (If you entered this information on the PAR-Q, please feel free to indicate "see PAR-Q.")
This field is required.
Injuries/Surgeries Properly Rehabilitated?
Have your injuries/surgeries been properly rehabilitated?
This field is required.
This field is required.
Do you have any chronic conditions (e.g., hypertension, diabetes)? Please list them. (If you entered this information on the PAR-Q, please feel free to indicate "see PAR-Q.")
This field is required.
Are you currently on any medications? Please list them.
Please provide any additional information or notes. (If you entered this information on the PAR-Q, please feel free to indicate "see PAR-Q.")