Consultation Form
Client Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
If you could wave a magic wand; what would you like to change? Ex: Your desire would to be able to run faster, run pain-free, get rid of neck pain, achieve a better posture, etc.
Health-Related Questions
Height (cm)
Therapist to fill in
Weight (kg)
Therapist to fill in
BMI
Therapist to fill in
Please describe your daily activity level
Sedentary (sitting most of the day)
Lightly Active
Moderately Active
Very Active
Do you engage in any physical activities or sports
Yes
No
If yes, provide details - What sport? How often do you exercise per week? How long is each session?
Are you pregnant (Female only)?
Yes
No
Are you a smoker?
Yes
No
Do you drink alcohol?
Yes
No
How much water do you drink per day?
How would you describe your current eating habits?
Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)
Yes
No
Do you follow any specific dietary restrictions or preferences? (e.g. vegetarian, vegan, gluten-free)
Do you have any food allergies or intolerances?
How often do you eat out or eat processed/packaged food?
Do you have any of the following conditions?
Anemia
Arthritis
Asthma
Cardiovascular problems
Diabetes Mellitus
Hypertension
Glaucoma
Bone problems
Respiratory issues
Migraine
Nothing
Other
Are you currently taking medications or supplements? If yes, what are the medications/supplements and for what purpose?
Where in the body do you feel discomfort? Indicate the location.
Do you feel the symptoms during or after training/a certain movement and how long does it stay?
What have you tried before to reach your fitness goal ex. strength program, rehab program, losing weight? Why did it not work for you?
Have you had any injuries or medical conditions in your body? If yes, please indicate the location/condition
Have you been previously hospitalized? If yes, please indicate when and why.
Did you undergo any surgeries? If yes, please indicate the type of surgery
How many hours of sleep do you get?
Please Select
4
5
6
7
8
What would you like to achieve with the end results of the assessment?
Weight loss
Gain muscles
Be physically fit
Sport performance
Improve overall health
Pain relief
Better posture
How much time in a week can you provide in this program?
Please rate you stress levels
Relaxed
1
2
3
4
5
6
7
8
9
Highly stressed
10
1 is Relaxed, 10 is Highly stressed
What package are you interested in?
One-on-One Training - R550 - Monthly
Eat well, Live well Program - R400 - Monthly
Dynamic Duo Program - R1700 - Monthly
Rehab and Stretch Program - R350 Once Off
Mommy Recovery Program - R699 once off
Sculpted Gym Program - R1200 Once Off
Sculpted Home Program - R1200 Once Off
Client Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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