Please fill out the New Client Registration Form if we’ve completed our first 15 minute consultation. New Client Registration CLIENT REGISTRATION FORM Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Primary Care Physician PCP Phone Number (###) ### #### Tell me more about you: Health goals: Exercise challenges: Past successes with exercise: Nutrition challenges: Other pertinent information: Height: Weight: Recent weight gain or loss? Yes No Medical History Surgeries (list all): Cancer: Yes No Heart problems: Yes No Circulation problems: Yes No Infection (C-diff, staph, Strep, other): Yes No High cholesterol: Yes No Chest pain or angina: Yes No Asthma: Yes No COPD/ Emphysema/Bronchitis/other lung disease: Yes No Kidney disease: Yes No Thyroid dysfunction: Yes No Diabetes: Yes No Arthritis type (rheumatoid or osteo): Yes No Chemical dependency / addiction (drugs, alcohol): Yes No Multiple Sclerosis: Yes No Parkinson’s disease: Yes No Epilepsy: Yes No Depression: Yes No Hepatitis: Yes No Stroke: Yes No Anemia: Yes No Concussion: Yes No High blood pressure: Yes No Are you pregnant now? Yes No Dizziness / lightheadedness: Yes No Any falls in the past year? Yes No Fatigue: Yes No Shortness of breath: Yes No Cigarettes, vape, cigars: Yes No How many days per week do you drink an alcoholic beverage? How many drinks per sitting? Client signature: * Type your full name below Date signed * MM DD YYYY Thank you! I’ll be in touch with you shortly.
