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Individual Coaching
In Home Meal Prep
Rolfing
Health Coach
Shop
Infrared Sauna
Psychotherapy
Contact
Client 360 - Health History Overview
Flex5 Coach
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Please choose a name of Flex5 Coach these forms are for.
Coach Darla
Coach Jack
Coach Mackenzie
Coach Petro
Coach Porschea
Coach Victoria
Other
Name
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First Name
Last Name
Phone
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(###)
###
####
Email Address
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Age
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Date of Birth
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MM
DD
YYYY
Place of Birth
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Country (if outside of US). State/City (if within US)
Current Height (ft/in)
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Current Weight (lbs)
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Weight six months ago (lbs)
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Weight one year ago (lbs)
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Would you like your weight to be different? If so, what? (lbs)
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What motivates you?
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Relationship status
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Please provide spouse's/partner's name if applicable
Children
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Please list their names if applicable
Pets
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Please provide their names if applicable
Significant Anniversaries
We would like to celebrate these with you!
Occupation
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Please list/discuss your main health concerns
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At what point in your life did you feel best?
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Any serious illnesses/hospitalizations/injuries?
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How is/was the health of your parents?
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What is your ancestry? Do you know your blood type?
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Do you sleep well? How many hours? Do you wake up at night? Why?
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I feel like I am getting enough rest on most days
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Yes
No
Sometimes
Any pain, stiffness or swelling?
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(Women only) Are your periods regular? How many day is your flow? How frequent?
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(Women only) Painful or symptomatic? Please explain.
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(Women only) Reached or approaching menopause? Please explain.
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(Women only) Birth control history.
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(Women only) Do you experience yeast infections or urinary tract infections? Please explain.
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Any digestive issues? Please explain.
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How many bowel movements do you have a day?
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Any allergies or sensitivities? Please explain.
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List any supplements or medications you are currently taking
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Any healers, helpers or therapies with which you are involved? Please list.
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What role does sports and exercise play in your life? Please explain.
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Have you worked with a trainer before? If so, what did you like the most and what did not work for you?
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What are your ideal appointment days?
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Please select your ideal appointment days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What are your ideal appointment times?
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Please select your ideal appointment times
6AM - 12PM
12PM - 4PM
4PM - 8PM
Varies
What was your diet like as a child? Please list separately for breakfast/lunch/dinner/snacks.
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What is your diet like now? Please list separately for breakfast/lunch/dinner/snacks.
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Will your family and/or friends be supportive of your lifestyle changes?
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What % of your food is home cooked? Do you cook?
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Where do you get the rest of your food from?
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Do you crave sugar, coffee, cigarettes, or have any major addictions?
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The most important thing I should change about my diet to improve my health is...
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Anything else you'd like to share/ask?
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Who is your insurance provider? Type n/a if this does not apply
What is your insurance provider ID? Type n/a if this does not apply
Thank you!
Flex5 by PetroFitness
All-Inclusive Holistic Fitness & Wellness Center in Uptown Charlotte.
Address :
428 E 4th Street, Suite 333, Charlottel, NC 28202
Email :
href="mailto:info@flex5clt.com">info@flex5clt.com