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

CONTACT NUMBERS

GENERAL INFORMATION

How did you come to hear from JVL Wellness & Lifestyle Centre?

How much water do you consume upon a daily basis?

Within the last year, have you been under 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 PressureInsomiaHormone ImbalanceClaustrophobiaHysterectomyHigh Stress LevelsEpilepsyCancerDepressionHigh CholestrolAsthmaThyroid 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 training before?

Have you ever used supplements before?

Have you ever used detoxification before?

Have you ever used supplements before?

Have you ever been on a special eating plan?

What is the goal that you would like to obtain this session?

Terms of Agreement

Client Signature



Date


NOTES FOR INTERNAL USE ONLY