Intake FormYour information is secure and stored on an encrypted server with limited access only by our administrators. We value your privacy and take all measure to ensure your security. Contact Information First Name Last Name Primary Email * Home Phone * Cell Phone * Cell Phone Carrier Please select oneAt&tTMobileSprintVerizone Date Of Birth (Mm/Dd/Yyyy) * Current Number Of Workouts Per Week * 01234567 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)* I have High Blood PressureI currently smokeI have heart problemsI have a family history of heart disease prior to age 50I experience dizzy spellsI have high cholesterolI currently have painI currently take medicationsI have blood sugar problems 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) * Δ