New Client Form

Demographics & Health History Form
Full Name*

First NameLast Name
Date of Birth?*
What is your age?*
What is your gender?
Contact Number*
Email Address*
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Number*
Employment Status*

Self-EmployedEmployedUnemployedStudentRetired
Occupation
Ethnicity

WhiteHispanic/LatinoAfrican AmericanNative HawaiianPacific islanderAsianMultiracialOther
How did you hear about us?

FacebookInstagramTictokOther
Check the conditions that apply to you ?*

AsthmaBlood disorderChronic Back PainConstipation/DiarrheaDepression/AnxietyDiabetesEndometriosis/AdenomyosisEpilepsyHair LossHeart DiseaseHigh blood pressureHIVHypothyroidJoint/Muscle PainMigrainesMental Health DiagnosisNeuropathySkin diseaseStrokeSpiritual concernPCOS/FirbroidsPhotosensitivityPregnancyTMJWeight gainOther
Do you have any medication allergies?*

YesNoNot Sure
Please list them.
Are you currently taking any medications or herbal supplements?*

YesNo
Please list them.
Have you had any surgery?*

YesNo
Please list them.
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
What is your goal or desired results?
ex. Weightloss, Body Contouring, Stress/Anxiety management, Natural pain/Inflammation management, Hormonal Balance, Digestive Issues, Grief, Chronic or Autoimmune disease management/prevention
Have you had Health Coachings in the past?

YesNo
Are you familiar with Holistic Health?

YesNo
Have you holistic therapies in the past?

YesNoN/A
Please provide details of previous therapy and outcome of results.
Any experience or interest in meditation, breathwork, hypnosis?
Do you exercise?

YesNo
Please provide what exercises and how often?
ex. 20-30min HIIT training 3-5days a week.
Services

For more information on each of the services, please visit our website at
For more information on our services please visit our website at alignbyzen.online or scan the QR code below

For more information on each of the services, please visit our website at
We have pre-selected the "Free Consultation" option. Please feel free to select any other services of interest.*

Free Consultation1 on 1 Health CoachingGroup CoachingHead SpaTherapeutic MassagesNatural Body ContouringPre/Post Op Education or Care
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Demographics & Health History Form

Services

For more information on our services please visit our website at alignbyzen.online or scan the QR code below