Kalescky Coaching Athlete Intake

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

What is your age? *

What is your occupation? *

How many hours a week do you work? *

How many hours a week do you want to train? *

Do you have any major medical issues I should be aware of? *

What is your past experience with sport? *

If you checked anything about, except none applies, please explain *

Cardiovascular Risk Factors *

Male older than 45 or Female older than 55 Your brother or father had a heart attack or heart surgery before age of 55 Your sister or mother had a heart attack or heart surgery before age of 65 You smoke, consume nicotine, or quit smoking recently (within past 6 months) Your blood pressure is above 140/90 mm Hg Your blood cholesterol level is >200mg/dl or LDL >130 or HDL>40 You have been physically inactive (you sit majority of your day) Your doctor has told you that you are obese (BMI >30) NONE OF THE ABOVE APPLY