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Client Intake Form

Please fill out and submit this for at least 24 hours prior to your appointment

Rate your general health Required
What do you need help with? Required
Do you regularly consume any of the following? Required
Do you have experience with the following: Required

RATE YOUR ENERGY LEVELS

MORNING
AFTERNOON
EVENING
Please indicate if you have had any of the following removed:
What is your activity level?
What kind of physical activity to you participate in?

Thanks for submitting!

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