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Who We Help
Unlimited Plans
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First Visit

CONSULTATION FORM

RECLAIM YOUR BODY

Book Your VIP

Wellness Experience

This is your first step toward feeling better, moving better, and seeing real results.

WHAT YOU GET:

✔ 1-on-1 consultation
✔ Personalized wellness plan
✔ Guided therapy session
✔ Expert recommendations

Name*

Phone Number*

Email*

General Wellness and Lifestyle

On a scale of 1-5, how would you rate your current overall wellness? (1=Poor, 5=Excellent

1

2

3

4

5

What are your top 2–3 health or wellness goals? (Examples: reduce stress, improve sleep, manage chronic pain, boost energy, lose weight, etc.)

Are there any specific areas of your health you would like to focus on first? (Physical recovery, mental wellness, mobility, immune support, etc.)

Health History & Current Challenges

Do you have any current or past health conditions we should be aware of?

Are you currently experiencing any of the following? (Check all that apply)

Poor Sleep

Chronic Pain

Stress or Anxiety

Low Energy or Fatigue

Inflammation

None of the Above

Sleep

On average, how many hours of sleep do you get per night?

How would you describe the quality of your sleep? (Restful, light, interrupted, trouble falling asleep, etc.)

Is improving sleep one of your wellness priorities? (Yes/No)

Yes

No

Nutrition

How would you describe your current nutrition? (Check any that apply)

Well balanced and consistent

I try to eat healthy but struggle with consistency

Im not sure where to start

I have specific dietary needs (please list): ___________

Other

Exercise & Activity

How active are you currently? (Check one)

I exercise regularly (3+ times per week)

I’m somewhat active but not consistent

I rarely exercise

Other

What types of physical activity do you enjoy or are interested in? (Walking, yoga, strength training, group classes, etc.)

Are you looking to add more movement or fitness into your routine? (Yes/No)

Yes

No

Habits & Stress Levels

On a scale of 1-5, how would you rate your current stress levels? (1=Very Low, 5=Very High)

1

2

3

4

5

What are your go-to ways of managing stress right now? (Meditation, exercise, social time, etc.)

Are there any habits you’d like to improve or change? (Better sleep, less screen time, healthier eating, daily movement, etc.)

Wellness Interests

Which types of therapies sound interesting to you? (Check all that apply—no pressure!)

Relaxation & stress relief

Pain management

Muscle recovery & performance

Detoxification

Weight loss support

Skin & beauty treatments

General wellness & prevention

Other

Routine & Preferences

How many times per week would you ideally like to visit Recharge?

Is there anything else you'd like us to know about your wellness journey, challenges, or preferences?

Limited VIP spots available each week.

Please only book if you’re serious about improving your body.

BodyRX Wellness Studio

3150 Bowling Dr
Birmingham, AL 35242

205-577-7303

Hours of operation:

Tuesday to Friday 10 am to 7pm

Saturday 9 am to 5 pm

Sunday 10 am to 2 pm

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These services are not intended to diagnose, treat, cure or prevent any disease. This Website offers health and fitness advice. This advice is designed for educational purposes only and is not intended to replace the advice, treatment, or diagnosis of a healthcare professional. Always consult your physician before beginning any therapy program. You agree that you assume all responsibility when choosing to act on any of the health or fitness advice contained on this Website. We reserve the right to amend this policy at any time without any prior notice to you.

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