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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
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Phone Number
*
Sex
*
Male
Female
Prefer not to say
Birthday
*
Height
*
Weight
*
GENERAL HEALTH & MEDICAL HISTORY
What medical concerns (e.g., recent surgery, pregnancy), if any, do you have at the present time?
*
Have you ever had any injuries or chronic pain? If yes, please explain.
*
Have you ever had any surgeries? If yes, please explain.
*
Has a medical doctor ever diagnosed you with a chronic disease (heart disease, high cholesterol, diabetes, high blood pressure)? If yes, please explain.
*
Indicate if you have had blood relatives with any of the following problems:
*
Cancer
Diabetes
Heart Disease
High Cholesterol
High Blood Pressure
Osteoporosis
Thyroid Disorder
None
Other
Do you have complaints about any of the following?
*
Appetite
Bleeding Gums
Bruising
Chewing or Swallowing
Constipation
Diarrhea
Edema
Indigestion
Menstrual Difficulties
Seeing in Dim Light
Sudden Weight Change
Stress
None
Other
Has your doctor ever said that you have a heart condition & that you should only perform physical activities recommended by a doctor?
*
Yes
No
Do you feel pain in your chest when you perform physical activities?
*
Yes
No
Have you had chest pain in the last month when you were not performing any physical activity?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have bone or joint problems that could be worse by changing your physical activity?
*
Yes
No
Is your doctor currently prescribing any medications for blood pressure or heart conditions?
*
Yes
No
Any other reasons why you should not engage in physical activity?
*
Yes
No
Do you use tobacco in any way?
*
Yes
No
Did you recently stop smoking?
*
Yes
No
Do you enjoy physical activity?
*
Yes
No
List any food allergies or intolerances. If none, please state "none".
*
Example: Peanuts, Eggs, Fish to name a few.
DRUG HISTORY
Please list any prescribed, over-the-counter, herbal, recreational drugs, or vitamin/mineral supplements you're currently taking. Or state "none".
*
FITNESS HISTORY
How often do you work out per week?
*
Never
Once
Twice
Three Times
Four Times
Five Times
Six Times
Seven Times
Eight and More...
Do you work out more than once a day?
*
Yes
No
What is your workout intensity level?
*
1
2
3
4
5
6
7
8
9
10
1 = Very Low Intensity (no sweat) 10 = Super High Intensity (lots of sweat)
What are your hobbies (reading, video games, etc.)? If none, please state "none".
*
What type of workouts?
*
Crossfit
Weight Lifting
Fitness Gym in General
Yoga
Walking
Hiking
Football
Soccer
Basketball
Tennis
Jogging
Long Distance - Marathon
Triathlon
Martial Arts/MMA
Hunting
Swimming
Surfing
Kite Surfing
Skiing
Snowboarding
Cross-Country Skiing
Ice Hockey
Ice Skating
Other
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)
None Of These Risks above Apply to me
*
YES
NO
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)
I understand these possible side effects and I will NOT hold DannyTheCoach responsible for any
*
YES
NO
Do you think you have adequate knowledge to safely engage in the use of BFR cuffs with DannyTheCoach?
*
YES
NO
By entering my Full Name below I herewith consent & agree to use BFR with DannyTheCoach
*
Please type in your full legal name.
BFR DOCUMENTATION
What does BFR do?
Quick Guide PDF
More to come...
Submit
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Services
Details-Packages
Kids & Teenagers
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About
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Update Index
Contact
