Consultform – Pitzer Health Adventure

Section A – CLIENT INFORMATION

Name & Surname *

Mobile *

Occupation

Email Address *

Street Address

City *

State/Province

ZIP / Postal Code *

Country

HOME LANGUAGE

HEIGHT IN CM *

CURRENT WEIGHT *

Select your BLOOD TYPE *

DATE OF BIRTH *

AGE *

NEXT OF KIN

Name & Surname

Phone

Section B – MEDICAL HISTORY

Select Quantity *

State Ages *

#12 – LIFESTYLE ACTIONS *

Smoke *YesNo

Smoke Per Day *

Alcohol Consuption *YesNo

Alcohol Consumption Per Week *

Caffeinated drinks *YesNo

Caffeinated Drinks per day *

Is WATER your main source for Hydration? *YesNo

Water Consumption Per Day *

Hours of sleep per night *

Chiropractic

Day

Month

Year

When last did you visit a Chiropractor. (Leave empty if never).

Physiotherapy/Biokinetics

Month

Day

Year

When last did you visit a Physiotherapist/Biokinetic. (Leave empty if never).

#16 – INJURIES

#17 – SURGERIES

#18- ALLERGIES *

CONFIRM NO ALLERGIES *Confirm None!

#19 – WHICH OTHER HEALTH PROGRAMS / PRODUCTS HAVE YOU TRIED IN THE PAST?

Section C – LIFESTYLE

#1 – BREAKFAST

#2 – RATE YOUR DIET / EATING HABITS

#3 – HOW OFTEN DO YOU EAT OUT OR HAVE TAKEAWAYS PER WEEK?

#4 – HOW MUCH DO YOU SPEND ON FOOD PER DAY?

#5 – RATE YOUR GENERAL ENERGY LEVELS

#6 – RATE YOUR STRESS LEVELS *

#7 – HOW OFTEN DO YOU EXCERCISE PER WEEK?Excercise

#8 – TYPE(s) OF EXERCISE

Section D – MARKETING

Authorization for photos. *YesNoI hereby grant PITZER HEALTH ADVENTURE PTY LTD permission to take photos of my process to monitor my progress.

Authorize use of progress *YesNoI hereby grant PITZER HEALTH ADVENTURE permission to make use of my progress for marketing purposes;

Authorize use of identity. *YesNoI herby grant PITZER HEALTH ADVENTURE PTY LTD to display my identity (Name Only)..

Where did you hear about us? *

Blur my face *YesNo, not necessary