Client Info Form
All Current and Potential Zen and Vitality clients are asked to complete this form so Zoa can give you her very best service!
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Best way to contact you
*
Text Message
Email
Phone Call
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you agree to receive emails from Zen and Vitality? Check your email inbox for a confirmation email - please click the link. You might need to look in promotions/spam/junk for the first email.
*
Yes you may email me
No I opt out of any informative emails from Zoa
Who should I thank for referring you?
*
What is your preferred payment method?
*
Cash
Check
Credit/Debit Card
Whatever I remember to grab
Which wellness services interest you?
*
Movement Classes
Functional Wellness and Testing
Local Food Access
Detox
Stress/Pain Relief
Not sure yet
Overall Wellness - Please help!
Other
Emergency Contact
*
Name and Phone Number
Are you recovering from an injury or surgery? If so, please tell me about it
*
What are your main wellness concerns?
*
Which Areas of Wellness do you want my help addressing?
*
Emotional
Environmental
Financial
Intellectual
Occupational
Physical
Social
Spiritual
What Body/Mind Issues are you dealing with or have you had in the past?
*
Allergies (especially if you carry an epi-pen)
Anxiety
Arthritis/Fibromyalgia/Cranky Joints (some days are better than others)
Balance/Equilibrium problems (no tipping over!)
Cancer
Cognitive decline of any type
Depression
Diabetes (need to watch blood sugar and exercise/diet)
Glaucoma (need to reduce inversions)
High Blood Pressure (whether medicated or not)
None (I have no reason to see a doctor)
Other (tell me more)
Pelvic Floor/Diastisis Rectii/Hernia problems (supported neutral spine work)
Pregnancy/Postpartum for less than 1 year (congrats!)
Recovering from surgery or injury
Respiratory challenge (breathing is important)
Scoliosis (one sided movements are great!)
Spinal disk bulge or herniation (let's keep your spine strong)
What else do you want me to know?
Submit
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