Intake Form

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Contact Information

First Name

Last Name

Primary Email *

Home Phone *

Cell Phone *

Cell Phone Carrier

Date Of Birth (Mm/Dd/Yyyy) *

Current Number Of Workouts Per Week *

Health History

Describe Current Workouts (I.E. Weight Lift, Pilates, Running, Etc.If None, Just Put None) *

Medical History (Select All That Apply To You. Select Multiple Ones By Holding “Ctrl” Button And Left Clicking The Mouse)*

If You Currenty Have Pain Anywhere, Please Explain *

Emergency Contact and Medical Contact

Emergency Contact Name *

Emergency Phone Number *

Primary Care Physician Name

Physican Phone (If Unknown, Name City He Or She Is In)

How Did You Hear About Our Program? *

If Referred By A Current Client, Please Give Us Their Name To We Can Thank Them

Your GOALS And FRUSTRATIONS

Short Term Goal (4weeks) (Make It Measureable With A Deadline) *

Long Term Goal (6-12months) *

What Are You Most Frustrated With When It Comes To Getting In Shape? *

What Is Your Biggest Obstacle/S When It Comes To Getting In Shape? *

Why Did You Decide To Come To Body Solutions Today And Not Last Week Or Month? *

What Are The Main Benefits That You Would Like To Achieve (Be Specific) *