Performance Optimization Activation Form

Integrated Wellness Performance Activation Form

Provide your current performance, recovery, nutrition, and health details for data collection—upload any wearable/testing files if available.
This clinical intake is designed to collect performance, recovery, nutrition, and safety information for provider review before training or protocol activation. Completion does not provide medical diagnosis or clearance, and any positive safety response requires review before strenuous exercise.
Patient Identification

Please provide your identifying details to link this intake to your record.
Unique Patient ID
Date of Submission

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Performance Goals and Sport Context

Tell us about your sport, goals, and training background.
Sport or Activity
Primary Performance Goal
Upcoming Event Date (if any)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Training Age (years of experience)
Weekly Training Schedule (days, types, durations)
Current Strength Metrics (e.g., lifts, reps, weights)
Current Endurance Metrics (e.g., distances, times)
Current Speed Metrics (e.g., sprint times, pace)
Equipment Used (e.g., shoes, wearables, tools)
Medical and Surgical History

Please provide the following history details before continuing.
Medical and Surgical History Details
Cardiovascular and Exertional Safety Screening
Instruction: Any positive response requires provider review before strenuous exercise or protocol activation.
Chest pain or pressure with exertion or at rest
Unexplained fainting or near-fainting
Unusual shortness of breath
Palpitations or known arrhythmia
Uncontrolled high blood pressure
Known heart disease or prior cardiac procedure
Family history of sudden cardiac death before age 50
Calf swelling or suspected blood clot
New neurologic symptoms during exercise
Injury, Neurologic, and Functional History

Include injury history, concussion history, training changes, and any current limitations.
Injury or Pain History (describe any relevant issues)
Concussion History
Current Training Load and Recent Changes
Current Functional Limitations
Medication and Treatment Review

List all current and recent medications, supplements, and treatments.
List all prescription medications, over-the-counter medications, supplements, peptides, hormones, stimulants, anticoagulants or antiplatelet agents, and performance-enhancing substances.
Include dose, frequency, reason for use, prescribing clinician when applicable, and any recent changes.
List any medication allergies and prior serious adverse reactions.
Include the medication, reaction type, severity, and when it occurred.
Cardiovascular History
Recovery and Physiologic Monitoring

Share recovery, sleep, nutrition, and physiologic monitoring details.
Sleep Quality (hours/night, patterns)
Heart Rate Variability (HRV)
Resting Heart Rate (RHR)
Recovery Status (describe how you feel recently)
Soreness Level (rate or describe)
Stress Level (rate or describe)
Nutrition Overview (general habits, timing, types of food)
Average Daily Protein Intake (g or servings)
Average Daily Carbohydrate Intake (g or servings)
Hydration Habits (amount, frequency, type)
Supplements Used (types, brands, dosages)
Menstrual or Reproductive Context (if applicable)
Signs of Low Energy Availability (e.g., fatigue, mood, performance)
Eating-Disorder or RED-S History
Pregnancy Status (if applicable)
Practical Programming Constraints

Tell us what training time and equipment access look like.
Number of Realistic Training Days per Week
Typical Session Duration (minutes)
Upload Wearable or Testing Data (optional)

Cancelof
Provider Review, Medical Clearance, and Recommendations

This section is provider-locked until reviewed. Completion of this form does not provide diagnosis, medical clearance, or emergency care.
Safety Symptoms Experienced During Exertion (e.g., dizziness, chest pain, fainting)
Provider-Contact Urgency
Consent to Review Information and Accuracy Confirmation
Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Integrated Wellness Performance Activation Form

Patient Identification

Performance Goals and Sport Context

Medical and Surgical History

Cardiovascular and Exertional Safety Screening

Injury, Neurologic, and Functional History

Medication and Treatment Review

Recovery and Physiologic Monitoring

Practical Programming Constraints

Provider Review, Medical Clearance, and Recommendations