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.
Under 18 years old
18 - 24 years old
25 - 34 years old
35 - 44 years old
45 - 54 years old
55 - 64 years old
65 - 74 years old
75 years or older
E.g., increase flexibility, reduce pain in knees, decrease anxiety, etc
Past injuries or genetic abnormalities
Please be specific
Current health conditions
E.g., MS, fibromyalgia, diabetes, etc
How healthy do you consider yourself?
How flexible are you?
Do you participate in physical activity now, and, if so, what?
What physical activities have you participated in in the past?
E.g., high school football, swimming, track, gymnastics, etc
How do you see yourself in 5, 10, 20 years?
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