contact us

Use the form on the right to contact us.

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1003 Diamond Ave
South Pasadena, CA, 91030
United States

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Fit-Fax Plus: Wellness Consult Form

Fit-Fax Plus Intake Form

 
Name *
Name
(This will forever remain private and secure)
BODY IMAGE/SELF-ESTEEM
MEDICAL HISTORY
Any family Type 2 diabetes, high blood pressure, cancer, metabolic syndrome, etc.?
Please note any chronic pain, digestion issues, headaches, high blood pressure, pre-diabetes, etc.
Please note any bouts of situational depression or anxiety.
Please include dosages. If you are on birth control, please note what type.
Please include dosages.
Please note any recent changes in period duration, frequency, intensity, etc.
NUTRITION
LIFESTYLE
For example: 5 am wake Coffee 6-7 Am Run Shower Drive 9-10 am @ Work at 10 am 10 am breakfast 2 pm Lunch 4 pm Grab Snacks 6-7 pm Drive Home 8 pm Dinner 11 pm Bed
ACTIVITY/MOVEMENT
Please note any sports or activities you enjoy.
Please note any broken bones, surgeries, torn tendons, etc.
MINDFULNESS
Please check the following kitchen items you own/use:
Please check the following skills you have practiced:
ACCOUNTABILITY