First Name
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Last Name
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Phone
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Email
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Which area of the body are you most interested in improving?
Neck
Shoulders
Arms
Back
Lower Back
Stomach / Waist
Hips / Glutes
Legs / Thighs
Which of the following outcomes are most important to you?
Improve Sports Performance
Anti-Aging
Improve Lifestyle
Improve Overall Health
Lose Weight / Decrease Body Fat
Gain Weight / Increase Muscle Mass
Improve Social & Recreational Activities
Reduce Anxiety & Depression
Pre- or Post-Rehabilitation
Improve Self Confidence
Other
Has your physician ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
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Yes
No
Do you feel pain in your chest when you perform physical activity?
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Yes
No
In the past month, have you had chest pain when you were not performing any physical activity?
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Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
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Yes
No
Do you have a bone of joint problem that could be made worse by a change in your physical activity?
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Yes
No
Do you partake in any recreational physical activities? (golf, skiing, etc.) Which?
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Do you have any additional hobbies? (reading, video games, etc.) Which?
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Have you ever had any injuries or chronic pain? If YES, please explain.
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Have you ever been diagnosed with a chronic disease, such as heath disease, hypertension, high cholesterol, or diabetes? If YES, please explain
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Are you currently taking any medication? If YES, please explain.
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Please enter any other comments/concerns you have.
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