First Name
Last Name
Date of Birth
Gender
Phone Number
Email Address
Street Address
City/Suburb
State/Province
Zip/Postal Code
Emergency Contact Name
Emergency Contact Phone Number
Primary Care Physician Name
Primary Care Physician Phone Number
Current Medical Conditions (if any).
Past Medical History (including surgeries, hospitalizations, etc.).
Current Medications & Supplements (please list all).
Allergies (food, medications, environmental).
Do you experience any of the following? (Check all that apply)
Chronic Pain
Anxiety
Depression
Insomnia/Sleep Disturbances
Digestive Issues
Stress/Burnout
Low Energy
Other:
Are you currently receiving any other form of therapy or treatment? (e.g., Physical therapy, psychotherapy, etc.)
What are your current activity levels? (e.g., Sedentary, Lightly active, Moderately active, Very active)
Do you have any dietary restrictions or preferences? (e.g., Vegetarian, Vegan, Gluten-free, etc.)
What are your primary wellness goals?
Stress Reduction
Weight Management
Improved Fitness
Enhanced Mental Clarity
Overall Well-being
Other:
What specific outcomes are you hoping to achieve through our programs?
On a scale of 1-10, where 1 is 'being not at all' and 10 is 'being extremely, how committed are you to achieving your wellness goals?
On a scale of 1 to 10, where 1 is 'no stress at all' and 10 is 'extreme stress, what are your current stress levels on a daily basis?
What are your current sleep patterns? (Average hours of sleep per night, quality of sleep)
What are your current eating habits? (Typical meals, frequency of meals, etc.)
What are your current exercise habits? (Type of exercise, frequency, duration)
What does "integrated wellness" mean to you?
Individual Programs:
Group Programs:
Which programs are you most interested in?
Are you interested in individual or group programs, or a combination?
Individual
Group
Combination
What days of the week are you available?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What time of day are you available?
Morning
Afternoon
Evening
What is your budget for wellness programs?
$0.00−$100.00/month
$100.00−$300.00/month
$300.00−$500.00/month
$500.00+/month
Based on your health history and goals, which of the following programs do you believe would be most beneficial for you, and why? (Refer to the program options above)
Are there any limitations or concerns that might affect your ability to participate in certain programs? (e.g., Physical limitations, time constraints, financial constraints)
Do you have any specific preferences regarding the type of instructor or coach you would like to work with? (e.g., Experience, personality, approach)
Are you open to trying new wellness modalities or approaches?
How do you envision your ideal wellness journey with us?
What are your expectations for communication and support from our team?
I understand that the information provided in this form will be kept confidential and used for the purpose of developing a personalized wellness program.
I consent to participate in the selected wellness programs and agree to follow the guidance and instructions provided by the instructors and coaches.
I acknowledge that I am responsible for informing the instructors and coaches of any changes in my health or medical condition.
I understand that wellness programs are not a substitute for medical treatment and that I should consult with my physician for any health concerns.
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