Client History Form

Instructions for completing the form below

Completing this form is optional, but it is very helpful 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 Form
This is your login email. If you would prefer to use another email address you may enter it here.
Date of Birth is used only for statistical purposes.
Gender *
Preferred measurement units *
Used for calculating health stats - waist-to-hips ratio and BMI

Measure the waist at the level of the navel (belly-button)
Measure round the widest part of the hips
Health measurement
To calculate your hight in inches, multiply your hight in feet by 12 and add the inches.
Weigh before breakfast
Body Mass Index

Measure the waist at the level of the navel (belly-button)
Measure measure round the widest part of the hips
Health measurement
Weigh before breakfast
Body Mass Index
Over-the-counter (non-prescription) medications and supplements. If none, enter "None"
Are you currently under a doctor's care? *

Please be as specific as possible
Please specify Medication / Dose / Frequency. - If none, enter "None"
We will not contact your doctor without your explicit permission.
Your doctor's City / State / Country
Your doctor's phone number with area code (and country code if not in the USA).
Have you read and understood the Terms and Conditions? *
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.
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