Parental Fitness Evaluation Intake Questionnaire
Complete this intake questionnaire so the evaluation can better understand family fitness habits, goals, and support needs. Do not include sensitive medical information.
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Child/Dependent
*
Please Select
Parent
Legal Guardian
Foster Parent
Step-Parent
Other
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child/Dependent Intake Details
Child/Dependent First or Preferred Name
*
Number of Children Being Evaluated
Fitness Evaluation Profile
Current activity level
*
Sedentary
Lightly active
Moderately active
Very active
Competitive athlete
Other
Typical weekly activity or exercise routine
Main fitness goals
*
Improve endurance
Build strength
Increase flexibility
Improve balance/coordination
Weight management
Boost overall energy
Return to consistent routine
Other
Activity limitations, preferences, or additional notes
Submit
Should be Empty: