Client History Form

Instructions for completing the form below

Completing this form is required for all new clients. It is necessary for deciding the best course of action for you. Please fill it in as accurately and completely as possible. It will be used to optimize our recommendations to best suit your current state of health and fitness. You can also do it later by accessing Update Client History from the Dashboard

If you have not yet completed the breathing test and breathing questionnaire please do this now before submitting the form below.

Client History Form for New Clients

Client History Update

Name

Email *

This is your login email. If you would prefer to use another email address you may enter it here.

Please describe any health concerns you have *

Please tell us what you expect from the course(s) *

Please list your OTC medications and supplements taken regularly *

Over-the-counter (non-prescription) medications and supplements. If none, enter "None"

Are you currently under a doctor's care? *

Yes

For what complaint(s) are you being treated? *

Please be as specific as possible

Please list your prescription medications, one per line *

Please specify Medication / Dose / Frequency. - If none, enter "None"

Name of your Doctor *

We will not contact your doctor without your explicit permission.

City / State / Country

Your doctor's City / State / Country

Phone Number

Your doctor's phone number with area code (and country code if not in the USA).

Any other questions or comments not covered by the above?

Terms and Conditions

Have you read and understood the Terms and Conditions? *

Yes

It is necessary to read the Terms and Conditions and selecting 'Yes' to be allowed to submit this form. You may read the Terms and Conditions in another window by clicking the link above.

If you are human, leave this field blank.