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Milly Friedman
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ABOUT
COACHING
The Grounding Path
The Rooted Path
Intake Nutrition and Movement
BIRTH SERVICES
Birthgiver's Path 1:1 Support 1 year
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Nutrition and Movement
CLIENT INTAKE
First Name
Last Name
Date of Birth
*
required
Email Address
Phone
Occupation
When it comes to nutrition and movement, what are your primary goals right now?
What does your current workout routine look like?
Describe what a typical week looks like for you please include how many days per week you can realistically commit to moving your body
How would you describe your current eating habits? Do you follow a specific approach?
Do you have any food preferences restrictions or major dislikes?
Do you have any injuries, limitations or conditions that I should know about when creating your movement plan
How's the doctor ever said you have a heart condition or that you should only do physical activity recommended by a doctor?
yes
no
Do you have pain in your chest during physical activity?
yes
no
Do you lose balance because of dizziness or have you ever lost consciousness?
yes
no
Do you have a bone joint or other condition that could be made worse by a change in physical activity?
yes
no
Are you currently taking any medications that may affect your ability to exercise safely?
yes
no
Is there any other reason you believe you should not participate in physical activity or follow a structured plan?
yes
no
Is there anything you would like me to know to best support you?( health,emotional,lifestyle, or environmental factors)
I confirmed that the information provided above is accurate to the best of my knowledge, and I understand that it is my responsibility to consult a healthcare professional before starting a new exercise program
Submit Intake
Your intake has been received
I’ll begin building your plan and you’ll hear from me soon.
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