New Client Intake Form - Wholebody Systems

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Get Answers in 15-minutes: (404) 998-5507 | info@wholebodysystems.com

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Get Answers in 15-minutes: (404) 998-5507 | info@wholebodysystems.com

Research
Technology
Locations
Testimonials
Contact Us

Name
First Last
Phone
Email
How Did You Find Us?
Address
Street Address City State ZIP Code
Birthday
MM slash DD slash YYYY
Height (inches)
Weight (pounds)
Emergency Contact Name
First Last
Phone
Primary Care Physician
First Last
May we contact your primary care physician regarding your case?
- Yes
- No
Will you allow bioDensity to use your data for research?
- Yes
- No
Do you currently engage in exercise on a regular basis?
- Yes
- No
What is your physical activity like on an average day?
- Not Active
- Moderately Active
- Very Active
How healthy do you consider yourself to be?
- Not Healthy
- Moderately Healthy
- Very Healthy
Check if you have ever been diagnosed or experienced any of the following:
- Current Pregnancy
- Pulmonary Embolism
- Acute Hernia
- Spinal Disc Injury
- Acute Thrombosis
- Neurological Disorders
- Migraines
- Epilepsy
- Cardiovascular Disease
- Recent Infections
- Pacemaker
- Implantable Defibrillator
- Cancer
- Tumors/Polyps
- Retinal Conditions
- Metal Pins/Plates
- Joint Replacement
- Recent Operation
- High Blood Pressure
- High Cholesterol
- Low Bone Density
- Diabetes
- Blood Clotting
- Stroke
Describe your history of exercise in detail, from as young as you can remember up to your current routine:
List and explain any musculoskeletal injuries or surgeries you have had:
Describe any chronic aches, pains, or physical ailments that currently experience:
List any medications, therapies, or other treatments that you are currently taking:
What is your main purpose for interest in this program?
Bone Density Test Scores (if applicable)
Max. file size: 100 MB.
If you have them available, please upload a copy of your bone density test results.

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Work with a certified exercise specialist who will customize your 15 or 30-minute sessions to improve your overall physical status. Our goal is to maximize the function of your body by restoring strength, balance, flexibility, posture, and endurance.

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