JMB Meal Plan Questionaire

DATE:

Date

HOME PHONE:

NAME:

WORK PHONE:

ADDRESS:

PAGER/CELL NO.

CITY/STATE/ZIP:

EMAIL:

example@example.com

IN CASE OF EMERGENCY, CALL:

GENERAL HEALTH & NUTRITION QUESTIONS:

Gender:

Height:

Birth date:

Date

Weight:

Body fat %

Weekly Exercise Information: Explain in detail what type of resistance exercises, cardiovascular or sports activities you perform on average during a 7-day period.

Exercise/Activity Days/week Duration

What Is Your Daily Activity Level?

Which Best Describes You?

What Are Your Goals?

What Is Your Goal Weight?

Fill in any medical conditions:

Which of the following best describes you?

I can eat practically anything and won't gain weightI find it very hard to gain weightI can lose or gain weight by adjusting my activity level and eating habitsI find it difficult to lose weight

Any Medications?

Please list average day of eating in one 24 hour period. Be sure to include snacks and beverages, including water. Also, show approximate amounts:

Food/Beverage:_

Make a list of your favorite foods.

Make a list of foods that you dislike.

What time do you normally wake up?

What time do you normally go to bed?

If you smoke, how many years have you smoked?

If you drink alcoholic beverages, what and how many per day?

Are you allergic to any kind of food? If so please list:

Have you ever been on a meal plan before?

YesNo

What were your results?

Have you ever had your body fat tested before?

YesNo

If yes, how was it tested and when?

Choose Your Meal Plan

6 Week8 Week12 Week16 Week

I, TO DESIGN A WEIGHT MANAGEMENT PROGRAM FOR ME TO ENHANCE MY

AGREE TO ALLOW JMB-FITNESS CONSULT,

HEALTH & FITNESS GOALS. I WILL

FOLLOW THAT PROGRAM TO THE BEST OF MY ABILITY AND I WILL NOT HOLD JMB-FITNESS OR ANY ONE RELATED PERSONS OR PARTIES PERSONALLY LIABLE

ILLNESSES OR INJURIES THAT MIGHT OCCUR DUE TO A SUDDEN CHANGE IN MY

EATING HABITS. I UNDERSTAND THAT JOSHUA BANKES IS NOT A REGISTERED OR

LICENSED DIETITIAN, NOR A MEDICAL PRACTITIONER. THIS WEIGHT MANAGEMENT PROGRAM DOES NOT REPLACE THE EXPERT ADVICE OR MEDICAL

OWN PRIVATE DOCTOR. I HAVE GIVEN JMB-FITNESS ALL NECESSARY

INFORMATION ABOUT MYSELF TO PREVENT ANY POSSIBLE COMPLICATIONS.

Signature:

Print Name:

Date:

Date

HOLD HARMLESS Sellers: JMB-FITNESS and Purchasers ( )

Hold Harmless and Indemnification Agreement

, the undersigned (“the Purchasers”) hereby warrants that I will indemnify and hold harmless JMB-FITNESS known hereafter as (“the Sellers”), and its officers, directors, agents and employees. This indemnification and hold harmless warranty extends to Sellers, individually and separately, and, the corporation’s successors, and subsidiaries, as against any and all claims, demands, actions, and causes of action, including personal injury, and all other liability whatsoever, including, but not limited to, costs, attorney’s fees and/or judgments which arise out of the use of the JMB-FITNESS weight management program. The undersigned, as Purchaser(s) further warrant the program is to be utilized within the State(s) of the Sellers corporation, its agents, directors, officers, employees and individuals named in paragraph one of this Hold Harmless and Indemnification Agreement, against any and all claims for liability and/or damages, arising from any and all violation(s) of Codes, Statutes, Licensing Procedures, Licensure Examinations and/or Registration Requirements, of such state(s), which govern the practice of dietetics and/or weight management and/or nutritional counseling and/or advise, whether known or unknown to the Purchaser(s) at the time of purchase and subsequent use with the public of the JMB-FITNESS weight management program(s Such indemnification includes, but is not limited to costs, attorney’s fees, and damages, whether or not reduced to judgment and judgments which might arise from such claims, law suits, and/or administrative filings. The indemnification includes all costs and attorney fees incurred by the Sellers in the investigation and defense of any claim enumerated in paragraphs preceding prior to a determination of an exact date of an occurrence and/or incident and/or violation upon which such alleged claims may be based. It is further understood and agreed by the Purchaser(s), that the consideration for this Indemnification and Hold Harmless Agreement, benefiting the Seller, its agents, directors, officers, employees and the individuals named in the paragraphs preceding is the “JMB-FITNESS content of the program”. Signature of Purchaser(s), confirms that Purchaser(s) have agreed to be bound by the terms of the Indemnification and Hold Harmless Agreement and are contractually bound to indemnify the Sellers and its agents, directors, officers, employees and the individuals named in paragraphs preceding, and such obligation includes the responsibility to pay any and all costs and attorney’s

, and it will hold harmless and indemnify

fees which may be incurred by the Buyer in defending its agents, directors, officers, employees and individuals named in the paragraphs preceding.

Seller's Name

Signature

Purchaser's Name

Date