Create Client Report

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Please complete all 6 steps of the form. You must click the green "Save Client Report" button on the bottom of Step 6 to complete the process.

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Multipage

Step 1 of 6 Trainee Information

Enter the name of the person who will be trained.
Leave blank if client is not to receive the report. If you provide an email address, we will set up an account for you (if one does not exist) and email you a copy of your report. In some cases, an email is required.
Uncheck the trainer name to remove from Client Report. Having a Trainer on a client report gives the trainer access to the client report.
Date of Birth *
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Step 2 of 6 Personal Information

Medications
How many of these medications do you take daily?
Conditions
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Step 3 of 6 Physical

Things I would like to change
Autonomic
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Sleep
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
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Step 4 of 6 Social

Things I would like to change
Social
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
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Step 5 of 6 Issues related to mood

Stress
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Anxiety
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Depression
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Anger
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Fear
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
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Step 6 of 6 Issues related to cognition

Attention
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Self-Control
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Creativity
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Learning
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Memory
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Thinking
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue

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