Energize Shanti
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The first step to explore Energize personal training and empowered healing is to complete this short assessment.

Please complete this short personal history form to receive your FREE 15 minute phone consultation! Your responses and contact info will be kept confidential, and I will follow up with you after I receive this to schedule an appointment.




    Full Name:
    Phone Number:
    Email Address:
    Date of Birth:
    Occupation:

  1. Have you experienced any of the following during the past 6 months?
    (Select all that apply) Dizziness Shortness of breath Nausea Pain in your chest area Pain in any of your joints Muscular pain Surgery
    Comments:

  2. What are your personal health and fitness goals?

  3. What exercises/activities do you currently enjoy? Hiking Biking Cycling Yoga Weight Training  Swimming  Pilates / Core work
    Other:

  4. On a scale of 1 (very little) to 10 (a lot), what would you say your stress level is on average?

  5. Have you suffered any injuries or trauma in the last 6 to 12 months?

  6. On most days do you feel:

  7. Any other questions or comments?

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