Reassessment Uptake

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First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

What are your current goals for the next 12 weeks?

How is your body feeling? Do you have any new issues or injuries?

Body Scan - Check all that apply

Tightness / Stretch

Custom Nutrition Program

Create lean muscle / tone / strength

Lose weight / Lean out

Custom Workout Program

Stress reduction / Breathing

Injury Recovery / Prevention

Improving Habits / Lifestyle

Recovering from life event

Other...

Do you have a PT?

Yes, see regularly

No

Are you clear to start a new workout program?

yes

no, unsure

Signature

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Raleigh, North Carolina

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