Nutritional Assessment
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Email *
Name: *
Phone: *
Age: *
How many people are in your household? *
If receive aid, what is your monthly snap/food stamp budget? *
Please list any health concerns or chronic illnesses in your household. *
Please check all that applies *
Required
Please list any medications *
Food and Lifestyle
These questions will help determine how to best coach you based on your lifestyle.
Do you or any member of your household, have food allergies? Please specify. *
Please list your family's eating habits. What's a typical breakfast meal, snack, lunch and dinner meal? *
List any dietary obstacles that are hindering you/your family from eating healthier. *
What are you hoping to accomplish? *
Client agrees to have doctor’s consent if concerns arrive after completion of client’s health questionaire. This agreement contains the entire agreement of the parties, and there are no other promises or conditions in any other agreement whether oral or written. Please sign/type initials below. *
Client must begin program within 7 days after their initial consultation. If a client misses a session/call during scheduled time, without prior notification, client will be removed from the program.  Please sign/type initials below. *
I give my permission for the above information to be made available to Coach P. and staff. I also give permission for my physician to be contacted for any concerns or a letter of approval if needed. I understand wellness coaching and nutritional counseling are advisory and should be used as educational tools. Coach P. or staff may not make any medical diagnoses, claims and/or substitute for a personal physician’s care. It is our role to partner with you to provide ongoing support and accountability as Coach P. creates an action plan to aid in meeting/maintaining your family's nutrition goals. Client understands that Coach P. does not and cannot guarantee success or any particular result. While we shall use our best professional efforts to achieve a successful result, we can make no warranty or guarantee. We work with each client according to their lifestyle, outlook and commitment. Results may vary. Please sign/type if you agree to the terms of service. *
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