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Client Intake Form
Number of Children
Ages of children
Past Exercise and Yoga Experience
Emergency Contact Name:
Emergency Contact Phone #:
Current Medical Conditions:
Past Medical Conditions:
Medical Procedures, Surgeries, Past Therapies and Dates:
Do you have pain? And if so where?
What is the average number or hours that you sleep per night?
Average amount of 8 oz servings of water consumed per day?
Describe your diet and your nutritional intake?
Describe your energy level:
Describe your stress level:
What does your current exercise routine look like if you have one. What exercises, how long and how many times per week?
How do you feel about your body? Is there anything that you would like to change?
What are your wellness and fitness goals?
I confirm that the information given in this form is true
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