download-mobilehealthandfitness.docVIP

Please answer questions as accurately as possible. Your responses will be treated in a confidential manner. A Client Demographics Name: Address: ZIP: Home Phone: Mobile Phone: Fax #: E-mail: D.O.B. Referred by: What is your height? What is your current weight? At what body weight did you, or would you, feel best at? How would you characterize your current lifestyle? Highly Stressful Moderately Stressful Low in Stress Contacts: Doctor: Phone: Hospital: Fax #: Contact In Case of an Emergency: Name: Phone: B Coronary Artery Disease CAD Risk Factors Are you a male older