Please fill in our online consultation form, read and answer all questions faithfully.

    CONTACT NUMBERS

    GENERAL INFORMATION

    How did you come to hear of JVL Wellness & amp; Lifestyle Centre?

    How much water do you consume upon a daily basis?

    Within the last year, have you been under a physicians care or surgery?

    Are you currently on any medication?

    Do you suffer from any allergies?

    Are you pregnant?

    Are you breastfeeding?

    Do you smoke?

    Do you suffer/have you suffered from any of the following conditions in the past 12 months? (Tick if applicable)

    Heart ProblemsHigh Blood PressureSystematic DiseaseLow Blood PressureInsomniaHormone ImbalanceClaustrophobiaHysterectomyHigh Stress LevelsEpilepsyCancerDepressionHigh CholesterolAsthmaThyroid ConditionDiabetesLack of ConcentrationSpinal InjuryLower Back PainSlipped DiscWeight ProblemsFatigueBlood Vessel Disorder

    Please specify if you have any other conditions that you would like to bring to the consultants attention?

    TRAINING, SUPPLEMENTS AND EATING SPECIFICS

    Have you ever had exercise training before?

    Have you ever used supplements before?

    Have been on a detox?

    Have you ever used supplements?

    Have you ever been on a special eating plan?

    What is the goal that you would like to obtain?

    Terms of Agreement

    Client Signature



    Date


    NOTES FOR INTERNAL USE ONLY