ATELIER Initial Assessment
Share your health, goals, and scheduling preferences so we can prepare for your consultation.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Appointment Details
How did you hear about us?
*
Please Select
Friend or Family
Social Media
Google Search
Website
Business Card
Gym or Studio
Physician or Therapist
Event or Workshop
Other
Services Interested In (Select All that Apply)
*
Personal Training
Corrective Exercise
Mobility/Flexibility
Recovery
Online Training
Nutrition Coaching
Other
Primary Goal
*
Please Select
strength
muscle gain
fat loss
pain relief
mobility
athletic performance
wellness
other
Current Pain or Limitations
Current Pain or Injuries
Pain level
No pain
1
2
3
4
5
6
7
8
9
Worst pain
10
1 is No pain, 10 is Worst pain
Medical History
Medical Concerns
*
Yes
No
Medical Concerns - brief explanation
Lifestyle
Current Lifestyle
Sedentary
Lightly Active
Moderately Active
Active
Highly Active
Nutrition Overview
Current Nutritional Habits
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Availability & Scheduling
Preferred days
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred time of day
*
Please Select
Morning
Midday
Afternoon
Evening
Flexible
Consent
I confirm that the information provided is accurate and complete|I understand that I am responsible for notifying the provider of any changes|I consent to the use of my information for consultation and service planning
*
I confirm that the information provided is accurate and complete
I understand that I am responsible for notifying the provider of any changes
I consent to the use of my information for consultation and service planning
Electronic Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Short note: More details will be discussed during the consultation.
Submit
Submit
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