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?
YesNo

Are you currently on any medication?
YesNo

Do you suffer from any allergies?
YesNo

Are you pregnant?
YesNo

Are you breastfeeding?
YesNo

Do you smoke?
YesNo

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? YesNo

Have you ever used supplements before? YesNo

Have been on a detox? YesNo

Have you ever used supplements? YesNo

Have you ever been on a special eating plan? YesNo

What is the goal that you would like to obtain?

Terms of Agreement

hereby warrant that I am physically and mentally fit to proceed with the training and treatments offered by JVL Wellness and Lifestyle, which I hereby voluntarily undertake. I have read and understand this form and have answered it accurately. By signing this form, I hereby indemnify and hold harmless JVL Wellness and Lifestyle and all related entities, management, staff and employees and assistants against any claim which may arise from any injury, loss or damage to either person or property from whatsoever cause arising.

Client Signature

Date

NOTES FOR INTERNAL USE ONLY