Address:

Email:
Phone Numbers:

Date Of Birth:

In Case Of Emergency:

Primary Physician:

I am glad you found us – who referred you?

INFORMED CONSENT

MISSED & CANCELED APPOINTMENTS: To cancel an appointment without charge, you must contact Revive Life at least 24 hours before your scheduled appointment. If you fail to cancel at least 24 hours in advanced, you will be charged a $25 fee and may be charged in full for a `no call, no show’ or session cancelled within an hour of scheduled time. Due to the nature of unforeseen circumstances, Revive Life understands and will allow a client to cancel a scheduled appointment one time and one time only without prior notice of at least 24 hours without being charged. After that one time, the client will be charged for all cancellations that do not adhere to the policy stated above. Thank you for observing customary office procedures.

Have you read these terms?

CURRENT GOALS

1. List three goals you would like to achieve with your participation here in Revive-Life? These could be related to your body, movements, general health, emotional life or other.

2. What is your biggest WHY for wanting to achieve your goals?

3. What discourages you and causes you to go off track?

MOVEMENT HABITS

1. Currently, do you have time in your day to commit to 15 or 20-30 minutes of movement practices?

Yes
No

2. What is your occupation?

Tell me a little about your typical day at work:

3. How would you describe your stress level?

4. What activities are you currently unable to do easily or not at all?
5. What activities do you want to do, but aren’t doing currently?
6. What activities hobbies do you engage in on a regular basis?

HEALTH HISTORY

The information provided in the Initial Health History will be used to determine your present health and possible future risks. All information given will remain private and will only be disclosed to your doctor if necessary.

1. When was the last time you had a physical examination?

2. If you have been told that you have any chronic or serious illness, please list them.

3. Please list any injuries, surgeries or traumas that you have experienced, even if they are very old.

4. Is there anything else about your health that we should know?

Availability:

When would you like to begin?

What days are your preference?

After clicking submit, your browser will redirect you to your email client. If you have your email set up, just send away….
If your browser says you have no email client set up, copy the code given to an email addressed to catethomas3@yahoo.com