GHI SIGNATURE HEALTH SOLUTIONS
Intake Form
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FIRST/LAST NAME *
PHONE NUMBER *
ADDRESS *
EMAIL *
SOCIAL MEDIA LINKS
MARITAL STATUS *
CHILDREN *
If Yes, Children Ages
MEDICAL ISSUES *
MEDICATIONS AND WHAT YOU TAKE THEM FOR *
STRESS LEVEL 1-10 *
NO STRESS
EXTREME STRESS
SLEEP LEVEL 1-5 *
NO SLEEP
GREAT SLEEP
HOW MANY HOURS OF SLEEP *
DO YOU TAKE CAFFEINE PRODUCTS *
WATER CONSUMPTION *
NO WATER
REQUIRED WATER
ENERGY LEVELS *
NO ENERGY
GREAT ENERGY
EXERCISE *
NO EXERCISE
EXERCISE EVERY DAY
HOW OFTEN BOWEL MOVEMENT *
DO YOU SUFFER FROM ANY OF THE FOLLOWING? *
Required
HAVE YOU HAD COVID-19 *
HAVE YOU HAD COVID-19 VACCINE *
ANY COVID RELATED SIDE EFFECTS? *
ARE YOU INTERESTED IN INCREASING YOUR METABOLISM? *
WHAT ARE YOUR GOALS REGARDING WEIGHT AND BODY SCULPTING? *
TARGET AREAS *
Required
ARE YOU INTERESTED IN JOINING FREE OUR SUPPORT GROUP *
ARE YOU INTERESTED IN ONE AND ONE COACHING *
ARE YOU INTERESTED IN LEARNING MORE ABOUT OUR MEMBERSHIP PACKAGES AND DISCOUNTS *
HOW DID YOU HEAR ABOUT US? *
COMMENTS
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