Distant Client Health Assessment Survey

Client Information

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* 1. Contact Information

Name *

City/Town *

State/Province *

ZIP/Postal Code

Email Address *

Phone Number *

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* 2. Best method of contact:

Phone call

Text

E-Mail

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* 3. Best Time of Day to Contact

Morning

Afternoon

Evening

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* 4. Date of Birth (MM/DD/YY)

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* 5. Age

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* 6. Current Weight (pounds)

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* 7. Weight (and/or Pant Size) 3 years ago

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* 8. Current Height (Feet-Inches)