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Client Intake Form
First and Last Name
Email
Phone Number
What is/are your goal(s) for our work together?
Why is this goal important to you?
Are you ready to commit to the Success Path (working out with me twice weekly, doing your 10-minute home work out twice weekly, setting and achieving goals toward simple but effective lifestyle changes) laid out for you in order to achieve your goals?
Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
*
Yes
No
Have you ever experienced unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
*
Yes
No
Do you ever feel faint, dizzy, or lose balance during physical activity/exercise?
*
Yes
No
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
*
Yes
No
If you have diabetes (type 1 or 2), have you had trouble controlling your blood sugar (glucose) in the last 3 months?
*
Yes
No
Do you have any other serious health conditions that may require special consideration for you to exercise?
*
Yes
No
Describe your current physical activity/exercise level in a typical week. What are you doing and for how long?
Is there anything else you would like to share with me?
I declare that the info I’ve provided is accurate & complete.
I agree that I have read Laibility Waiver and fully understand its contents and voluntarily agree to be bound to all of its terms.
Liability Wavier.
I have read and fully understand and agree to Studio Da Capo's
Terms and Conditions.
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