High blood Pressure?
Levels:
Cigarette Smoking?
Diabetes?
Type:
Family history of heart disease?
Who/Age:
Do you work out regularly?
How Often?
Are you currently taking medication?
Explain:
Knees:
Explain:
Lower Back:
Explain:
Neck/Shoulder:
Explain:
Hip/Pelvis:
Explain:
Any Other Issues:
Explain:
How Did You Hear About Us?
If friend, please provide name:
Name:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Primary Physician Phone:
Emergency Contact Phone:
Email:
Class Start Day
Time:
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Do you have or do any of the following pertaining to your health? .....
Do you have or do any of the following pertaining to your health? .....
5:30-6:15am and 9-9:45am $129/month(M, W, F)
6:00-6:45pm $89/month (M and Thurs)
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