Iron Sharpening Ironing

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Healing the community one family at a time

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Iron Sharpens Iron
Siblings Community Healing Circle

Iron Sharpens Iron

Name*

Phone*

Email Address*

Address

Street, City, State, Zip code

Are you currently taking any exercise program?*

YesNo

Height *

How tall are you?

Weight*

How much do you currently weigh?

Do you have the following conditions?*

AnemiaArthritisAsthmaCardiovascular problemsDiabetes MellitusHypertensionGlaucomaBone problemsRespiratory issuesMigraine

Other medical condition not listed.

Are you a smoker?*

YesNo

If yes, how often?

Are you pregnant (Female only)?

YesNo

If yes, how far along?

Do you drink alcohol?

YesNo

If yes, how often?

Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)*

YesNo

What do you usually eat for breakfast?*

What do you usually eat for lunch?

What do you usually eat for dinner?*

Are you currently taking medications? If yes, what are the medications and for what purpose?*

Have you had any injuries in your body? If yes, please indicate the location*

Have you been previously hospitalized? If yes, please indicate when and why.*

Did you undergo any surgeries in the past? If yes, please indicate the type of surgery*

What are your goals in this program?*

Weight lossGain musclesBe physically fitSport performanceImprove overall health

Other goals not listed.

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Complete the form on the left and our intake coordinator will contact you to set up the initial consultation in 24 - 48 hours.

"Health is wealth"

Home
About
Our Team
Privacy Practices
Contact
Contribute
Iron Sharpens Iron
Siblings Community Healing Circle

Improving the community through the lives of the individuals and families we serve...