New Client Intake Form - MOSAIC HEALTH

Name *

First

Last

Email *

Phone *

Date of Birth *//

Address *

Address Line 1

Address Line 2

City

State

Zip Code

What are your health goals?

Choose all that apply

What are the biggest challenges to reaching your goals?

Choose all that apply

In the past, what techniques, diets, behaviors, etc, have you tried to reach your goals?

Has your doctor ever said you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Do you feel pain in your chest when you perform physical activity? *

In the past month, have you had chest pain when you were not performing any physical activity? *

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

Please list all medications and/or supplements you currently take:

Do you follow any special diet program or have diet restrictions or limitations for any reason? Please Explain: