Bodies By Akeem
Client Intake Form

New Client Onboarding

Please complete this form before your consultation. All information is strictly confidential and used solely to design the most effective program for you.

Personal Information

Activity Level & Goals

Occupation & Lifestyle

Is your current occupation stressful?
Does your occupation require extended sitting?
Does your occupation require extended standing?
Does your occupation require you to wear shoes with heels?
Do you eat sugar?

Current Nutrition & Diet

Do you have any food allergies?

Chronic Pain & Surgery History

Chronic Neck pain?
Had Neck surgery?
Chronic Shoulder pain?
Had Shoulder surgery?
Chronic Elbow pain?
Had Elbow surgery?
Chronic Wrist pain?
Had Wrist surgery?
Chronic Back pain?
Had Back surgery?
Chronic Ankle pain?
Had Ankle surgery?
Chronic Toe pain?
Had Toe surgery?
Any other chronic pain not listed above?

Medical & Surgical History

Have you ever had Appendectomy?
Have you ever had Carotid Endarterectomy?
Have you ever had Cataract Surgery?
Have you ever had Breast Biopsy?
Have you ever had Debridement (wound, burn, or infection)?
Have you ever had Cesarean Section (C-Section)?
Have you ever had Dilation & Curettage (D&C)?
Have you ever had Cholecystectomy (Gallbladder removal)?
Have you ever had Skin Graft?
Have you ever had Coronary Artery Bypass?
Have you ever had Hemorrhoidectomy?
Have you ever had Mastectomy?
Have you ever had Hysteroscopy?
Have you ever had Mastectomy (Segmented/Partial)?
Have you ever had Hysterectomy?
Have you ever had Colectomy?
Have you ever had Inguinal Hernia Repair?
Have you ever had Tonsillectomy?
Have you ever had Prostatectomy?
Have you ever had Partial Colectomy?

Current Conditions

Do you currently have / have history of Heart disease?
Do you currently have / have history of Kidney disease?
Do you currently have / have history of Liver disease?
Do you currently have / have history of Hypertension (high blood pressure)?
Do you currently have / have history of Hypoglycemia?
Do you currently have / have history of Stroke (history of)?
Do you currently have / have history of Diabetes?
Do you currently have cancer?

General Health Screening (PAR-Q)

The Physical Activity Readiness Questionnaire (PAR-Q) is a standard pre-exercise screening tool. Please answer all questions honestly.

Has your doctor ever said you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you exercise?
In the past month, have you had chest pain when NOT performing exercise?
Have you ever had fainting spells or loss of balance?
Have you had any recent surgery?
Do you have a bone or joint problem that could be made worse by physical activity?
Are you currently on blood pressure medication prescribed by your doctor?
Do you know of any reason why you should not engage in physical activity?
Do you currently smoke cigarettes?
In general, do you enjoy exercise?

Consent & Signature

I understand that the information I have provided about myself, including my medical condition and history, is truthful and correct. I further understand that my information will be kept strictly confidential. Bodies By Akeem, LLC will not share, sell, or redistribute any part of my personal information without my expressed written consent. I hereby indemnify Bodies By Akeem, LLC, its trainers, employees, and vendors against any adverse reaction sustained as a result of treatment provided.

By typing your name above, you agree this constitutes a valid electronic signature.