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            Ashkee's 
              Client & Student Questionnaire

              ** This is only to be filled out by current students 
              or clients at Ashkee's request. 		
          

        

         
        

        

         
        

          
 
            
             
              
First 
                Name:   
                
                

                Last Name: 
                
                

                Address: ... 
                
                

                Address: ... 
                
                

                City:  .........  
                
                

                State: ....... 
                
                

                Zip Code:... 
                
                

                

                Home Phone: 
                
                

                Work Phone : 
                
                

                Cell Phone: .. 
                
                

                

                E-mail: .....  
                
                

                

                You are:

                
                Male

                
                Female

                

                Age:  
                
                

                Height: 
                

                Weight: 
                

                

                Birth Date: Year: 
                
                Month: 
                
                Day: 
                
                

                

                Time Of Birth: 
                
                : 
                
                
                

                

                Place Of Birth: 
                
                

                

              
Marital 
                Status:

                
                Single

                
                Married

                
                Longterm Relationship

                
                Divorced 
                
                Widowed 

                

                Children: 
                
                

                

                

                Health Issues:

                
                

                

                Emotional Issues:

                
                

                

                

                Six things you would like to change about yourself:

                

                1. 
                 
                
                

                2. 
                
                

                3. 
                 
                
                

                4. 
                 
                
                

                5. 
                
                

                6.