Client Confidential Intake

I appreciate your interest in a consultation engagement with Summit Coach. Please complete this form and submit it before our call. It will help us be more productive and focus our plans on how we can help.

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Name *

First

Last

Age *

Height *

Weight *

What is the altitude of your home town? *

When was your last medical checkup? *

• Within the last 12 months
• Between two and four years ago
• More than five years ago

Do you have any injuries that would impact climbing? (i.e. back, knee or shoulder issues, etc.) Please explain if yes.

Do you have any chronic diseases or illness that would impact your climbing? (asthma, diabetes, etc.) Please explain if yes.

In a typical week, how often do you exercise? *

• I don't exercise regularly
• Once a week
• Two to four days a week
• Five to seven days week

What is your usual exercise program? (Check all that all that apply) *

• Gym–machines and weights
• Cross Fit
• Running
• Cycling
• Sports (softball, basketball, football, hockey, etc.)
• Indoor Climbing
• Outdoor rock and ice climbing
• Hiking
• Walking
• Other
• I don't have a regular exercise program

What is your time to run 1 mile​/1.6 km on flat terrain? *

• Over ten minutes
• Eight to ten minutes
• Under eight minutes
• I haven't run in years
• I don't run

What is the highest altitude you have ever reached climbing? *

Did you experince any of these altitude related issues?

• General fatigue but kept going
• General fatigue and turned back
• AMS: Acute Mountain Sickness (headache, nausea, vomiting, confusion, etc.)
• HAPE: Pulmonary Edema (fluid in the lungs)
• HACE: Pulmonary Cerebral (brain swelling)

What is the heaviest pack you've carried and for how many hours or days at one time? i.e. 70 pounds​/32kg on Aconcagua, 4-6 hours each day *

If you rock climb, what is the maximum grade you can lead? *

• 5.0 to 5.5
• 5.6 to 5.10
• 5.10+
• I only follow on a top rope
• I don't rock climb

If you ice climb, want is the maximum grade you can lead? *

• Water Ice (WI) 1 to WI3
• WI5 to WI5
• WI6+
• I only follow on a top rope
• I don't ice climb

How important is the price you pay for your climb relative to summiting, safety and a positive experience? *

• Very Important
• Important
• Neutral
• Somewhat Important
• Not Important at all

How important is summiting your mountain to you compared to the overall experience? *

• Very Important
• Important
• Neutral
• Somewhat Important
• Not Important at all

Please add comments on your climbing experience not already provided:

Have you ever climbed (not necessarily summited) any of these mountains?

• Swiss, French, Italian Alps (Mont Blanc, Matterhorn, Monta Rosa, etc.)
• Colorado 14ers
• California 14ers
• Alaska (Denali, Saint Elias, Foraker, Bona, etc.)
• Ecuador Volcanoes (Cayambe, Cotopaxi, Chimborazo, etc.)
• Bolivia (Pequeno Alamayo, Hyaena Potosi, etc.)
• Argentina (Aconcagua, Ojos del Salado, etc.)
• Mexico Volcanoes (Orizaba, Popocatépetl, Iztaccihuatl, etc.)
• Nepal Trekking Peaks (Island, Mera, Lobuche, etc.)
• India (Nanda Devi, Kamen, Saltoro Kangri, etc.)
• Pakistan 8000ers (K2, Nanga Part, Gasherbrum I/II, Broad Peak)
• Nepal/Tibet 8000ers (Cho Oyu, Manaslu, etc)
• Everest
• K2

Have you ever climbed with any of these companies?

• 8K Expeditions
• Alpine Ascents International (AAI)
• Adventure Consultants
• Asian Trekking
• American Alpine Institute
• Alpenglow Adventures
• Adventure Peaks
• Benegas Brothers
• Elite Expeditions
• Imagine Nepal
• Jagged Globe
• International Mountain Guides (IMG)
• Himalayan Experience (Russell Brice)
• Kobler & Partner
• Rainier Mountaineering Inc (RMI)
• Madison Mountaineering
• Mountain Trip
• Furtenbach Adventures
• Seven Summits Treks
• Tim Mosedale

Verify you are a human, please. *

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