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RE:WILD WITH JC
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Home
Kids Barefoot Shoes
Coming soon...
Adult Barefoot Shoes
Coming soon...
Free Ebooks
Book your FREE assessment
In-person FREE assessment
Online via Video FREE assessment
More
About JC
Privacy Policy
Re:Wild with JC's Client Health Screening
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Indicates required field
Name
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First
Last
Email
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DOB
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Occupation
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1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
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Yes
No
2. Do you feel pain in your chest when you perform any physical activity?
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Yes
No
3. In the past month, have you had chest pain when you were not performing any physical activity?
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Yes
No
4. Do you lose your balance because of dizziness, or do you ever lose consciousness?
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Yes
No
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
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Yes
No
6. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
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Yes
No
7. Do you know of any other reason why you should not engage in physical activity?
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Yes
No
8. Is there anything you'd like for me to know specifically?
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9. Apart from what you've mentioned during our conversations and assessment, are there any other injuries (ankle, knee, hip, back, shoulder, etc.) I should know about? If yes, please explain.
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Yes
No
9. If yes, please explain.
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10. Have you ever had any surgeries? If yes, please explain.
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Yes
No
10. If yes, please explain
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11. Has a doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? If yes, please explain.
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Yes
No
11. If yes, please explain
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12. Are you currently taking any medication? If yes, please list.
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Yes
No
12. If yes, please list.
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13. Do you have any food allergies? If yes, please list.
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Yes
No
13. If yes, please list.
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14. Do you confirm that you're willing to participate in a health and wellness programme that is designed to help you achieve a healthier lifestyle, but may also challenge some of your beliefs around health, movement and nutrition?
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Please write out yes or no
14. Print name
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15. DECLARATION: I hereby consent that all of the information I have provided to JC, via this form and in conversation is correct and accurate to the best of my knowledge and I will update JC of any changes ASAP.
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Please type yes or no
15. Print name
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16. COMMITMENT: I confirm that from this moment forward, I will give 110% to my health and wellness and the advice and guidance that I receive from JC.
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Please type yes or no
16. Print name
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Digital Signature
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Please print name
Today's date
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I agree to receiving marketing and promotional materials
Submit