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STEP 2: Please Complete This Intake Form Before Your 1st Session With Me

Please fill out this form so I can better serve you and your ongoing health journey.

Name*
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Your Phone #*
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Your Email*
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Age*
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Height*
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Weight*
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What is your body fat percentage?* (N/A if you don't know.)
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What is your body fat in pounds?* (N/A if you don't know.)
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What is your muscle / tissue in pounds?* (N/A if you don't know.)
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What is your resting heartrate?* (N/A if you don't know.)
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What is your BMR?* (N/A if you don't know.)
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What is your TDEE?* (N/A if you don't know.)
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What is your Exercise History?* (Leave as much detail as you'd like)
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What are your overall goals* (Leave as much detail as you'd like)
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High Cholesterol?* (YES or NO)
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High Blood Pressure?* (YES or NO)
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Diabetes?* (YES or NO)
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If Yes, Type 1 or Type 2?
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Have you experienced a heart attack?*
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If YES, date of heart attack?
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Stroke?*
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If YES, date of stroke?
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Cancer: currently?
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If YES, type of cancer?
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Osteoporosis?*
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Asthma?*
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Arthritis?*
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If YES, where is it located?
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Pregnant?*
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Other injuries, surgeries, conditions or health related information not listed above?
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