Transformation Challenge Intake Form CLIENT INTAKE FORM THIS FORM IS INTENDED FOR TRANSFORMATION CHALLENGE PARTICIPANTS ONLY. Transformation Challenge Intake Form Fall 2022 Transformation Challenge Intake Form Personal Contact InformationName(Required) First Last Phone(Required)Do you give permission to PF4U Coaches to call or text you? Y/N(Required) Yes No Email(Required) This is where our coaches will be sending your program information! Please double-check your spelling! Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about the Transformation Challenge?(Required)InstagramFacebookWeb SearchWord of Mouth ReferralOne of the PF4U CoachesOtherIf you were referred, please tell us from who! We would love to thank them but will not include your personal information. If a specific coach has referred you, please include their name here. Personal Health InformationAge(Required)Please enter a number from 12 to 99.Birthdate(Required) MM slash DD slash YYYY Height(Required) In feet and inchesCurrent Weight(Required)Please enter a number from 75 to 999.In poundsBody Fat PercentagePlease enter a number from 1 to 100.Only include if results are representative of your current physique. If are unsure of this value and within driving distance to our headquarters- consider trying our Body Composition Machine! Do you own a smart watch? If so, what kind?If you do own a smart watch, what is your estimated calorie burn? This is your daily MOVE amount on an Apple Watch or Daily Calorie Burn on FitBitAre you within 5 days of your last menstrual period?(Required)YesNoN/AAre you pregnant?(Required)YesNoAre you breastfeeding?(Required)YesNoDo you smoke?(Required)YesNoDo you drink alcohol regularly?(Required)YesNoIf so, how frequently? Have you been diagnosed with any chronic medical conditions?If so, please explain.Have you been prescribed any medications which you are to take on a regular basis?If so, please explain.How many hours of sleep do you receive PER night on average?(Required)Please enter a number from 1 to 23.What are your favourite activities/hobbies?(Required)On a scale of 1-5, how do you rate your health as a priority?(Required) 1 2 3 4 5 1= low priority, 5= top priorityOn a scale of 1-5, how does your support system rate their health as a priority?(Required) 1 2 3 4 5 1= low priority, 5= top priorityWhat is your current occupation?(Required) How many days/week do you typically work?(Required)Please enter a number from 1 to 7.How many hours/week do you typically work?(Required)Please enter a number from 1 to 99.Does your occupation require you to travel often?(Required)YesNoTraining InformationDo you have a preferred way to execute your physical activity?(Required) Resistance Training, Power Lifting, Yoga, Hiking, Endurance Training, Cardio, Group Exercise Classes, etc.On a scale of 1-5, how do you rate your current fitness level?(Required) 1 2 3 4 5 1= worst it’s ever been, 5= best it has ever beenNutrition InformationHave you ever tracked your food intake before?(Required)YesNoHow familiar are you with “macros” and “macro counting”?(Required) 1 2 3 4 5 1= poor, 5= excellentAdditional InformationWould you prefer the group meetings to be in person or virtual? In Person Virtual No Preference If you select in person, you must be able to commute to Lethbridge for the meetings.Do you have children? Yes - Young Children (0-10 years old) Yes - Older Children (11 years - adult aged) No What is your level of interest in the Personal Development aspect of the Transformation Challenge? Very Interested Open to learning more Not Interested at all If you are interested in Personal Development, which of the following topics interests you the most? Habit formation, identity shifts, becoming a leader, creating a compelling vision, and cultivating courage and trust Learning about how fat loss actually works, the female hormone component to weight loss and how to improve your mindset about dieting. If you were to set 1-2 health and wellness goals that you hope to achieve in the next year, what would they be?(Required)Please describe how your ideal coach would best support you in achieving these goals.(Required)Do you currently have (or have had within the past 12 months) high thyroid, peri-menopausal symptoms, a recent hysterectomy or have you recently went off of birth control?(Required)YESNOHave you been diagnosed with any of the following medical conditions: Hypertension, Diabetes, Cirrhosis or Diverticulitis?YesNoPAR-QPlease Note: If you have answered YES to any of the PAR-Q question below, it is imperative that Perfectfit4u receives a doctors note (uploaded below) before constructing your training programming. Has your doctor ever said that you have a heart condition or high blood pressure?(Required)NoYesDo you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?(Required)NoYesDo you lose balance because of dizziness or have you lost consciousness in the last 12 years? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).(Required)NoYesHave you ever been diagnosed with another chronic medical condition?(Required)NoYesIf so, please describe.Are you currently taking prescribed medication for a chronic medical condition?(Required)NoYesIf so, please describe.If yes, please describe: Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.(Required)NoYesHas your doctor ever said that your should only do medically supervised physical activity?(Required)NoYesDoctors Note UploadMax. file size: 300 MB.This upload is only required if you have answered YES to any of the above PAR-Q questions. Enter Today's Date(Required) MM slash DD slash YYYY Consent By checking this box, your are eSigning this form.I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed, and become invalid if my condition changes. I also acknowledge that #Perfectfit4u may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.NameThis field is for validation purposes and should be left unchanged.