Athlete intake form Name First Name Last Name Email * Phone (###) ### #### Emergency Contact * Name and Phone number What level of coaching are you interested in? Exclusive Premium Choice What type of coaching are you looking for? * Cycling Endurance Sports (Other than cycling) Wellness Business Coaching Lifestyle (Starting to get active and healthy) Three goals you would like to achieve * Are you allergic to any medications (Yes/No) * If yes please list. Do you feel pain in your chest when you perform physical activity? Yes Option 2 Is there anything else we should know? In the past month have you experienced pain anywhere including your chest/heart? * Select Yes No Medical Issues * Do you have or experience any of the following? Heart attack Heart disease Heart Disease Heart Murmur Hypertension Thyroid Problems If you're a female are you currently pregnant Asthma Wheezing Diabetes Epilepsy Anemia Broken bone/Fracture In the past few months have you been dizzy, out of breathe or pain while exercising? * Select Yes No Do you have knowledge of any reason why you shouldn't exercise or train? * Yes No Has a doctor cleared your for training with The Chad Andrews Coaching? * Please select Yes No Please list all medications you are currently on.. Any special needs or questions you may have? How did you hear about us? Have you read our waiver and cancellation policy? * https://www.thechadandrews.com/policies-and-procedures Yes No Thank you!
