FRESH FOCUS WELLNESS

FRESH FOCUS WELLNESS
PERSONAL TRAINING NUTRITIONAL COACHING THERAPEUTIC SOLUTIONS

Client Personal Information Form
NAME
DATE

MonthDayYear
Date
HOME ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL ADDRESS:
example@example.com
CELL PHONE
Format: (000) 000-0000.
OTHER PHONE
Format: (000) 000-0000.
OCCUPATION
EMPLOYER
EMERGENCY CONTACT:
NAME
PHONE
Format: (000) 000-0000.
RELATIONSHIP
508 W. Second St. Suite 120 Lexington, KY 40508 (859) 787 4363 tbrown@freshfocuswellness.com www.freshfocuswellness.com
FRESH FOCUS WELLNESS
PERSONAL TRAINING NUTRITIONAL COACHING THERAPEUTIC SOLUTIONS
GOALS
1. Do you smoke?

YesNo
2. Have you ever been diagnosed with
diabetes
high cholesterol
high blood pressure
asthma
If so, are you taking any medication for any of the above?

YesNo
Please list
DATE OF BIRTH

MonthDayYear
Date
HEIGHT
WEIGHT
WAIST
HIP
RATIO
RESTING HEART RATE
508 W. Second St. Suite 120 Lexington, KY 40508 (859) 787 4363 tbrown@freshfocuswellness.com www.freshfocuswellness.com
Should be Empty: