Please provide some general information to help us analyze your conditions for treatment.

*Required fields

Name of Client: (First, Middle, Last)*

Date:*

Email:*

Phone:*

Sex: Male Female

1. Based on your goal, please number the following options …in order of priority (1=high, 6=low)

2. My lifestyle is Sedentary Moderately Active Very Active

3. Smoke yes no

4. Style of Message firm medium nurturing

5. Do you have any medically related dietary concerns that may need attention during your stay?
(For example diabetics, gastrointestinal problems, kidney disease) yes no

6. Have you ever had high-blood pressure or hypertension?
If yes, please give details and dates. yes no

7. Do you have a history of any illness that may require frequent medical attention?
If yes please give details and dates. yes no

8. Is there a physical reason not mentioned why you should NOT follow an activity program if you wanted to?
If yes please give details. yes no

9. When was the last time you saw a physician? Please give details and dates.

10. How many times have you been treated for a dependency?
Please give details and dates.

11. Describe any bone/joint problems, handicaps, chest pains or severe dizziness?
Please give details.

12. When was last dental exam? Please give dates. Do you need care?
If yes please give details. yes no

13. In the past 7-days what types of drugs, medications, and alcohol have you used?
Please give details.

14. In the past 1-year what types of drugs, medications, and alcohol have you used?
Please give details.

15. Please list food restrictions or allergies:

16. Additional Comments: Occupation, Achievements, Objectives