KP Total Estate

Client Health Intake Form

Please complete this form honestly before your first session. Your responses help us build the right programme for your body.

This information is confidential and used solely to guide your fitness and wellness experience with KP Total Estate.

01 Participant Information

Your Details

Please enter your full name.
Please enter your date of birth.
Please enter your phone number.
Please enter a valid email address.
Emergency Contact
Required.
Required.
02 General Health Questions

Section 1 — PAR-Q+

Please read the following 7 questions carefully and answer each one honestly.

1. Has your doctor ever said that you have a heart condition OR high blood pressure?

2. Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

3. Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

5. Are you currently taking prescribed medications for a chronic medical condition?

6. 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.

7. Has your doctor ever said that you should only do medically supervised physical activity?

Based on your responses, you appear cleared for physical activity.
Based on your responses, you may require additional guidance. Kristie will review your intake and follow up before your first session.
03 Follow-Up Questions

Section 2 — Medical Detail

Please indicate if you have any of the following medical conditions.

2a — Heart Disease / High Blood Pressure

Do you have a history of heart attack?

Do you have heart failure?

Do you have a history of cardiac surgery or intervention (stenting, bypass)?

Do you have an implanted cardiac device (pacemaker / defibrillator)?

Do you have uncontrolled high blood pressure (systolic > 160 mmHg or diastolic > 100 mmHg)?

Do you have a known aneurysm?

2b — Metabolic Conditions

Do you have Type 1 Diabetes?

Do you have Type 2 Diabetes?

Do you have kidney disease?

2c — Musculoskeletal / Other

Do you have osteoporosis or significant osteopenia?

Do you have any condition that causes significant limitation to joint movement (e.g. rheumatoid arthritis)?

Do you have chronic pain that prevents or limits physical activity?

Do you have a spinal cord injury or neurological condition that affects your ability to exercise?

Are you pregnant, or have you given birth within the last 12 months?

Are you currently being treated for cancer or have you completed cancer treatment in the last year?

2d — Mental Health

Do you have a mental health condition (e.g. depression, anxiety, schizophrenia) that may affect your ability to participate in physical activity?

04 Current Physical Activity & Lifestyle

Section 3 — Your Activity Level

05 Nutrition Intake — Optional

Nutrition & Meal Planning

This section is for fitness clients whose plan includes nutrition coaching (such as the Rebuild & Rise tier). If your plan does not include nutrition, feel free to skip this entire section. None of these fields are required.

06 Declaration & Consent

Section 4 — Your Signature

I have read, understood, and completed this questionnaire. I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that this questionnaire is intended to identify individuals who may require additional guidance before starting a physical activity programme, and is not a medical diagnosis. I acknowledge that physical activity involves some inherent risk of injury and agree to inform KP Total Estate of any changes in my health status that may affect my ability to participate safely in physical activity.
Your signature is required.
Date is required.
Medical Clearance *

Please select one of the following before submitting your intake form.

Download the Medical Clearance Form

Print this form and take it to your healthcare provider. They will complete and sign it, and you can bring it back to Kristie or have them send it directly.

Open Form
Your decision to waive medical clearance has been noted and will be recorded with your intake submission. Kristie reserves the right to require clearance before beginning sessions if she determines it is necessary for your safety.

Thank you, there.

Your intake form has been received. Kristie will review your responses and be in touch before your first session. If you flagged any health conditions, she may reach out to discuss next steps.

Building the foundation that lasts.