Assessment Form | BRCmindandbody

First name

Last name

Email

Phone

Birthday

年

月

天

Emergency Contact Name

Emergency Contact Phone Number

Wellness Goals

Health and Medical Information

(This is to make sure you check with your primary physician prior to starting any therapy especially if you answer yes to any of the following:)

Do you have any chronic health conditions?

yes

no

If yes, please specify:

Are you currently taking any medication?

yes

no

If yes, please list:

Do you have any allergies?

yes

no

If yes, please specify:

Current Weight

Height:

BMI

Have you ever experienced claustrophobia?

yes

no

Are you pregnant?

yes

no

Do you currently engage in any wellness or fitness activities?

yes

no

If yes, please describe:

How many hours of sleep do you typically get per night?

On a scale of 1-10, how would you rate your current stress level?

On a scale of 1-10, how would you rate your current energy level?

Is there any other information you would like us to consider while creating your wellness plan?

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Wellness Goals

Health and Medical Information

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