Essentrics® Client Intake Form
This intake form is used to ascertain your desired goals and overall health needs/limitations for the safety of your training. Any information obtained from this form will only be used by Essentrics® with Jill Roth and will remain confidential.
Email address *
Name *
Your answer
Age *
Phone
Your answer
Objective/Goals
E.g., increase flexibility, reduce pain in knees, decrease anxiety, etc
Your answer
Past injuries or genetic abnormalities
Please be specific
Your answer
Previous surgeries/dates
Your answer
Current health conditions
E.g., MS, fibromyalgia, diabetes, etc
Your answer
Current medications/supplements
Your answer
How healthy do you consider yourself?
Poor
Excellent
How flexible are you?
Poor
Excellent
Do you participate in physical activity now, and, if so, what?
Your answer
What physical activities have you participated in in the past?
E.g., high school football, swimming, track, gymnastics, etc
Your answer
How do you see yourself in 5, 10, 20 years?
Your answer
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