Client Intake Form
Basic information about your health, lifestyle and physical experience
Name
Your answer
Birthday
MM
/
DD
/
YYYY
What inspired you to join the movement?
Your answer
favorite ways to move your body?
Your answer
Something you dream of accomplishing?
Do you have a regular physican? Are you cleared for exercise?
Your answer
Are you currently on any Medications?
Your answer
Current pain level?
Your answer
Have you had any surgeries? if so please include date (s)
Your answer
Injuries in the Past, please list. Current injuries with dates.
Your answer
Occupation?
Your answer
Physical Activities you enjoy?
Your answer
Do you cook for yourself? If so how many times a week?
Your answer
Where do you buy food?
Your answer
How much water do you consume daily?
Your answer
What are your fitness Goals?
Your answer
Best way to contact you? Include email and phone
Your answer
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