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CLIENT INTAKE FORM
Full Name
*
Date of Birth
*
Gender
*
Phone
*
Email
*
City & State/Country
*
Time Zone
*
Occupation
*
Typical work hours?
*
Typical work hours?
A
9-5
B
Shift Work
C
Self-Employed
D
Other:
Work Environment
*
Work Environment
A
Desk-Based
B
Active
C
Mixed
Do you travel frequently for work?
*
Do you travel frequently for work?
A
Yes
B
No
How many hours do you sit per day?
*
How many hours of screen time per day?
*
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