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