If you are interested in becoming a client, then please fill out this first-contact form. Completing the following information does not guarantee you will obtain client status; however, I cannot accept you as a client until this form is completed. THE INFORMATION YOU PROVIDE ME IS STRICTLY CONFIDENTIAL.   F I R S T - C O N T A C T Name: Mailing Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code: Country: Physical Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code: Country: Home Phone Number: Business Phone Number: Home Fax Number: Business Fax Number: email Address: Occupation: Age: Sex: male female Height: Weight: Percentage Body Fat: (if known) Signs and symptoms: Diagnosis: Goals: Do you smoke? Yes No If yes, how many cigarretes or cigars per day? Are you around someone that smokes? Yes No Do you drink alcohol? Yes No If yes, how much and how often? Do you use recreational drugs? Yes No If yes, how much and how often? List current medications you are taking: List any medications you have recently stopped taking: List any "over the counter" drugs you are taking: List any nutritional supplements you are taking: List any herbal supplements you are taking: List any known allergies and your reactions: List current injuries: List past injuries that have resulted in chronic problems: Have you had any surgeries? Yes No List surgeries and dates performed: Referred by: