Client Intake Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

USA Mailing Address *

Date of Birth *

Women: are You Pregnant? *

Yes No

Do You Have a Pacemaker? *

Yes No

Do you have diabetes or any other known blood sugar condition? *

Yes No

Are you under medical care to suppress your immune system? *

Yes No

Do you smoke? *

Yes No

Your health concerns or symptoms: *

Health conditions that have been diagnosed by a licensed doctor: *

Any known health challenges with your organs: *

Any past surgeries and removed organs: *

Any known allergies: *

Any medications you're taking and what they've been prescribed to treat: *

Any supplements / herbs / remedies your taking: *

Any medical or alternative treatments you receive or have recently received: *

Any serious car accidents? If so, how many? *

Quality of sleep and typical hours of sleep each night: *

Type(s) and amount of exercise each week: *

Briefly describe your dietary habits: *

Briefly describe your drinking habits, including typical use of water, coffee, juice, soda, alcohol in a day: *

What is your #1 goal from working with New Balance Wellness? *

I understand that Ana McCardell is a wellness coach and I freely submit this information to her. My personal information will be stored on her website service (Weebly) servers and will otherwise not be shared outside her practice except if required by law. She may share information without my personally identifiable information in order to seek solutions for me. *

I agree.