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GHI SIGNATURE HEALTH SOLUTIONS
Intake Form
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* Indicates required question
FIRST/LAST NAME
*
Your answer
PHONE NUMBER
*
Your answer
ADDRESS
*
Your answer
EMAIL
*
Your answer
SOCIAL MEDIA
Your answer
REASON FOR VISIT
*
PEMF
PEMF PTSD
PEMF BODY SCULPTING
PEMF PAIN MANAGEMET
COACHING
Other:
DESCRIBE REASON FOR VISIT
*
Your answer
MARITAL STATUS
*
Single
Married
CHILDREN
*
Yes
No
If Yes, Children Ages
Your answer
MEDICAL ISSUES
*
Your answer
MEDICATIONS AND WHAT YOU TAKE THEM FOR
*
Your answer
STRESS LEVEL 1-10
*
NO STRESS
1
2
3
4
5
EXTREME STRESS
SLEEP LEVEL 1-5
*
NO SLEEP
1
2
3
4
5
GREAT SLEEP
HOW MANY HOURS OF SLEEP
*
Your answer
DO YOU TAKE CAFFEINE PRODUCTS
*
Yes
No
Sometimes
WATER CONSUMPTION
*
NO WATER
1
2
3
4
5
REQUIRED WATER
ENERGY LEVELS
*
NO ENERGY
1
2
3
4
5
GREAT ENERGY
EXERCISE
*
NO EXERCISE
1
2
3
4
5
EXERCISE EVERY DAY
HOW OFTEN BOWEL MOVEMENT
*
Your answer
DO YOU SUFFER FROM ANY OF THE FOLLOWING?
*
STRESS EATING
DEPRESSION
SUGAR CRAVINGS
ANXIETY
SUBSTANCE ABUSE
BOREDOM
Required
HAVE YOU HAD COVID-19
*
Yes
No
Do not wish to answer
HAVE YOU HAD COVID-19 VACCINE
*
Yes
No
Do not wish to answer
ANY COVID RELATED SIDE EFFECTS?
*
Your answer
ARE YOU INTERESTED IN INCREASING YOUR METABOLISM?
*
Yes
No
Maybe
WHAT ARE YOUR GOALS REGARDING WEIGHT AND BODY SCULPTING?
Your answer
TARGET AREAS
FACE
NECK
ARMS
WAIST/BELLY
BACK
THIGHS
HIPS
OTHER
ARE YOU INTERESTED IN JOINING FREE OUR SUPPORT GROUP
*
YES
NO
MAYBE
ARE YOU INTERESTED IN ONE AND ONE COACHING
*
YES
NO
MAYBE
ARE YOU INTERESTED IN LEARNING MORE ABOUT OUR MEMBERSHIP PACKAGES AND DISCOUNTS
*
YES
NO
MAYBE
HOW DID YOU HEAR ABOUT US?
*
GOOGLE
FACEBOOK
INSTAGRAM
REFERRAL
Other:
COMMENTS
Your answer
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