Osteopenia Weight Training Program Intake Form
Please complete this form to help us tailor a safe and effective weight training program for your osteopenia needs.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name and Phone Number
*
Have you been diagnosed with osteopenia by a healthcare professional?
*
Yes
No
Please list any current or past medical conditions (e.g., osteoporosis, arthritis, heart conditions, injuries)
*
Are you currently taking any medications? If yes, please list them.
*
How would you describe your current level of physical activity?
*
Sedentary (little or no exercise)
Lightly active (light exercise/sports 1-3 days/week)
Moderately active (moderate exercise/sports 3-5 days/week)
Very active (hard exercise/sports 6-7 days a week)
Other
What are your primary goals for joining the Osteopenia Weight Training Program? (Select all that apply)
*
Increase bone density
Improve strength
Enhance balance and coordination
Reduce risk of falls
General fitness
Other
Please indicate any physical limitations, pain, or injuries that may affect your participation in weight training.
How confident do you feel about starting a weight training program?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Submit Intake Form
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