Client Intake Form

Please indicate YES or NO for the following:

HEART DISEASE

HIGH BLOOD PRESSURE

HYPER TENSION

CANCER

DIABETES

OTHER, PLEASE SPECIFY

PREGNANT

ON ANY MEDICATIONS

IF YES, PLEASE SPECIFY

ON ANY MEDICAL RESTRICTIONS

IF YES, PLEASE SPECIFY

RECIEVING MEDICAL TREAMENT

IF YES, PLEASE SPECIFY

HEALTH HISTORY

This section is all about YOU. I would love for you to share your hopes and goals for our time together! In order for me to design the safest and most effective program for you, please answer the following questions centered around what you would like to accomplish, what you enjoy, and what your challenges are :) Don’t be shy... YOU are totally going to crush this!

GOALS