Intake Process For Functional Patterns AZ, Signup Today

Name:

Phone:

Birth Date:

Current Date:

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Emergency Contact

Name:

Number:

Relationship:

Please describe your past and present training history (sports, working out, etc):

Other: (Please list any other relevant medical diagnoses)

Please list any medications or supplements you are currently routinely taking:

Are you on any form of hormone replacement therapy?

Have you had any surgeries in the past? If yes, please list with dates:

Is there anything else about your past medical history that you’d like us to know?

How do these issues affect your daily life (physically, mentally, emotionally) ?

What have you done to address these issues before coming to FP, and why don’t you think those modalities have worked for you?

How did you find out about Functional Patterns, and what are your goals with training?

Intake Form