New Client form New Client Form Welcome To kirstyredford.co.uk! Please Fill Out The Following Information Thoroughly So I Can Let You Know If You Are A Case I Can Accept And Help. Please Feel Free To Ask Any Questions If You Need Assistance. I Look Forward To Serving You! Name Address Email Birth Date Are you under a doctor’s medical supervision at this time? Yes No If Yes, for what? Are you in good health at the present time to the best of your knowledge? Yes No Are you taking any medications at the present time? Yes No If Yes, what medications? Do you take vitamin supplements? Yes No If Yes, what vitamins? Current injuries? Yes No Height Current Weight Goal Weight Do you drink coffee or tea? Do you drink pop / soft drinks? Snack habits Typical Breakfast Typical Lunch Typical Dinner Describe your energy level? Activity Level Inactive Light Activity Moderate Activity Heavy Activity Vigorous Activity Do you Smoke? Yes No On a scale of 1 to 10 with 10 being MOST committed, how committed are you to taking action and making a change in your life today? 1 2 3 4 5 6 7 8 9 10 What does your dream life look like? Preferred method of contact Telephone Email Acceptance I agree to Kirsty Contacting me using the details I have supplied within this form. ( For response purposes only) How Were You Referred To Me COMMIT TODAY!