Contact Us

About
ASD & Exercise
Personalized Exercise Plans
Group Exercise
Virtual Training
Contact Us

About
ASD & Exercise
Personalized Exercise Plans
Group Exercise
Virtual Training
Contact Us

Intake Form

Please fill out the Intake Form to set up a consultation. The form will be sent directly to one of our personal trainers who will contact you within 24 hours. We respect your privacy and will not share your information with anyone.

508-735-2949 info@adaptiveexercisenow.com

Name

Parent/Guardian Name

Phone

Date of Birth

Age

Weight

Address

City

State

Zip Code

School

Grade

Date of Latest IEP

IEP

YES No

Does the client have diabetes or have they been identified as having prediabetes?

YES No

Has the client been diagnosed as being obese?

YES No

Does the client have a family history of coronary or other atherosclerotic disease prior to age 50?

YES No

Does the client have a history of high blood pressure?

YES No

Does the client have an Epipen?

YES No

Does the client have a rescue inhaler?

YES No

Do you currently own exercise equipment in your home?

YES No

Do you have an in home gym?

YES No

Do you have a space or room in your home suitable for exercise?

YES No

Does the client have a history of seizures? (If yes, please explain)

Does the client have any allergies? (If yes, please explain)

Does the client have asthma? (If yes, please explain)

Subscribe to our Newsletter:

508-735-2949 info@adaptiveexercisenow.com

Review Us On Google

Schedule Consultation

Please fill out this brief form and one of our personal trainers will contact your shortly. Thank you.

Name

Phone

City & State