New Clients | Kathy Brown, M.S.

Health Declaration

Please fill out the following form to the best of your knowledge. Your answers will be kept CONFIDENTIAL ( * indicates required responses).

First name

Last name

Address

Phone

Email

Date of birth

Month

Day

Year

Are you under the care of a physician, chiropractor or other healthcare worker for any reason?

No

Yes

Are you suffering from a medical condition, illness or injury that would complicate your participation in an exercise program?

No

Yes

Has your doctor told you that you have a bone or joint problem that could be made worse by exercise?

No

Yes

If you answered YES to any of the questions above, please supply additional information.

Are you taking medications that could impact your exercise program?

No

Yes

Has your doctor told you that your blood pressure is too high?

No

Yes

Have you ever experienced any chest pain associate with exercise or stress?

No

Yes

If you answered YES to any of the questions above, please supply additional information.

I declare that the info I’ve provided is accurate and complete.

Signature: Please use your mouse or finger to sign then press NEXT.

Signature field is empty.

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