Stierli Health Consulting - Danny The Coach will get you back in shape. San Diego, California.
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BFR - INTAKE FORM

    BLOOD FLOW RESTRICTION (BFR) Intake Form

    CONFIDENTIALITY NOTICE: ALL OF YOUR INFORMATION IS SECURED, CONFIDENTIAL AND WILL NEVER BE SHARED WITH ANYBODY. This data helps DannyTheCoach to formulate a plan of action.


    DEMOGRAPHIC DATA

    GENERAL HEALTH & MEDICAL HISTORY
















    Example: Peanuts, Eggs, Fish to name a few.

    DRUG HISTORY

    FITNESS HISTORY


    1 = Very Low Intensity (no sweat) 10 = Super High Intensity (lots of sweat)



    BLOOD FLOW RESTRICTION (BFR) SPECIFIC QUESTIONS*
    Risk Assessment - Your Risk of Injury or Problems increase if you experience:
    • Deep Vein Thrombosis (DVT)
    • Pulmonary Embolism or history
    • Hemorrhagic/Thrombotic Stroke
    • Clotting Disorders (causes bruising)
    • Untreated Hypertension/Hypotension
    • Pregnancy
    • Medications
    • Rhabdomyolysis (Rhabdo)

    Side Effects - These are some but not all of the most common side effects*
    • Subcutaneous Bruising
    • Numbness & Tingling (loosen strap tension)
    • Delate-Onset-Muscle-Soreness (DOMS)


    Please type in your full legal name.

    BFR DOCUMENTATION
    • What does BFR do? Quick Guide PDF
    • More to come...
Submit

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  • Home
  • Services
    • Details-Packages
    • Kids & Teenagers
    • Outdoor Workouts
    • Corporate Solutions
  • About
    • Testimonials
    • Video Library
    • Anne The Coach
  • Updates
    • Update Index
  • Contact