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Client Paperwork

Client Paperwork

Please complete to the best of your ability
Name *
Name
Phone
Phone
Date of birth
Date of birth
Questionnaire
Section 1
1. How many time per week do you perform resistance training?
Resistance training includes: body weight movements, barbells, dumbbells, kettle bells, etc.
2. How many times per week do you perform cardiovascular training / endurance training?
3. Do you stretch and mobilize your body to maintain structural balance and energy flow on a regular basis?
4. When you take a deep breath, does you belly expand before your chest does?
Section 2
1. Do you have an overarching dream/legacy for your life?
2. Over the course of a week where is your average stress level?
3. How many hours do you work each week?
4. Do you love what you do?
5. Do you make time for introspection, self-reflection and a spiritual practice each day?
Section 3
1. Is your diet composed of mostly organic produce (fruits & vegetables)?
2. Do you eat pasture-raised/grass-fed, free-range meats?
3. How many meals/snacks (total times eating) do you have each day?
This includes all restaurants: fast-food, take-out, buffets, sit-down
5. Have you ever tried dieting in the past?
This is only straight water: coffee/tea, juice and water in food does not count
7. Do you drink from plastic water bottles?
8. Do you consume caffeine? If so, how often?
9. Do you drink alcohol? If so how often
Section 4
Health History
Are you experiencing any of the follow Health Challenges? If so please describe
Please include any and all health challenges and a detailed explanation:
Are you experience any of the follow symptoms? If so please describe
Medication - List any medication you are currently taking (prescribed or over the counter)
Please include: name, reason for taking, frequency, and dosage
Please include: name, reason for taking, frequency, dosage
Please include: name, reason for taking, frequency, dosage
Please include: name, reason for taking, frequency, dosage