WHAT SPECIFIC ISSUES DO YOU NEED ADDRESSED?

Many clients are referred by health practitioners. Please get them to circle some of the following issues they would like addressed. Or you can fill it out yourself and bring it in.

NAME: _____________________  AGE:___________

          Deep abdominal conditioning

          Shoulder stability

          Hip stability / Gluteal activation

          Flexibility

          Diabetes / High risk of diabetes

          Heart disease / High risk of Heart disease

          Thoracic posture

          Weight / Body Fat

          Strength / Muscle

Referring Practitioners Name: _____________________

Referring Practitioners Phone: _____________________