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Tell Me About YOU!

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Question 1 of 9

What are you hoping to get out of working with me?

Question 2 of 9

You have a magic wand, what do you want for yourself in the next 180 days?

Question 3 of 9

What do you know about yourself that could STOP you?

Question 4 of 9

Is there anything else you want me to know or want to know about me?

Question 5 of 9

Please check any that apply and we will discuss:

(Select all that apply)
A

Heart Disease

B

Pulmonary Disease

C

Diabetes

D

Family History of Chronic Heart Disease

E

High Blood Pressure

F

High Cholesterol

G

Smoking

H

Sedentary Lifestyle

I

Surgery

J

Chest Pain

K

Dizziness

L

Shortness of Breath

M

Irreg./Accel. Heart Rate

N

Osteoporosis

O

Arthritis/Joint Pain

P

Back Pain/Spinal Disorder

Q

Musculoskeletal Pain/Injury

R

Medication

S

New Choice

T

Other Medical condition or allergies

U

Injuries

Question 6 of 9

Are you pregnant?

A

Yes

B

No

Question 7 of 9

Please be advised that any information or advice I am giving you is based on my own experience and should not take the place of advice given to you by a medical professional. By entering into this agreement it’s understood that it’s always best to consult a medical professional prior to involvement in an exercise program.

A

Yes, I agree & understand.

B

No, I do not agree.

Question 8 of 9

Do you have the commitment for doing what it takes to get what you REALLY want in your life?

A

Yes, let's do this!

B

I'm not sure.

Question 9 of 9

Have you had comprehensive blood work done in the last year?

A

Yes

B

No

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