Check any of the following symptoms that apply to you:
	Back or Neck Pain, Stiffness, Soreness Headaches Pain between the Shoulder Blades Muscular Spasm and Tightness Pain, Numbness or Tingling in Extremities	Chronic Pain Painful Joints Excess Stress Dizziness or Loss of Balance Low Energy and Sluggishness

Over the last 12 months have you been involved in: select all that apply
	Auto Injuries Other Injury	Work Injuries	Sports Injuries
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How has your health condition impacted your life? i.e. prevented you from doing?

What health goals have you set for yourself recently or would you now like to set? check all that apply
	To initiate or improve upon a fitness/exercise program To lose excess body fat To build extra muscle To consume a healthier, more nutritious diet To participate in a preventative health plan to increase overall health and well-being Other:

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