Nutrition New Clients Needs Analysis

Name*

First NameLast Name

E-mail*

Phone Number*

Area CodePhone Number

Occupation *

To understand your daily activity levels

Birth Date*

MonthDayYear

Current Body Weight (kg)*

Please enter current body weight

Height (cm)*

Sex*

What do you want from the service? (You may want several)

Please fill out the questionaire below to the best of your ability. The more information we have the easier it will be to achieve your nutrition targets. Once you have sent this through I will arrange a phone call for your FREE CONSULTATION.

Out of all of the changes you'd like to make, which ones feel most important / urgent? List top 3 in preferential order.*

More detail the better.

Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body? If so, what?*

More detail the better.

Which of those things worked well for you, and why?*

Even just a little bit, and even if you might not be doing them right now.

Which of those things didn’t work well for you, and why not? (This can include being too difficult to integrate in your day to day life.)*

This can include being too difficult to integrate in your day to day life.

Until now, what has blocked you or held you back from changing these things?*

More detail the better.

Right now, how would you rank your overall eating / nutrition habits? 10 being 'Very Good' or 1 'Not Good'*

Why did you rate your nutrition with that particular number?*

Be realistic

What types of sports and / or exercise do you typically do? *

Outline training programs, weights, cardio, skilled sport practice.

If so, approximately how often & how long? *

List how many days, how long the sessions are, include walking to work etc.

How do you food shop? *

Home delivery, supermarket, someone else does it.

Who is the main cook in your household?*

State 'you' if applicable

How often do you cook?*

Do you eat out, cook everything etc

What are your short & mid-term goals with nutrition? *

Next 6 month to 2 years

Do you drink alcohol, if so how much per day / week?*

Next 6 month to 2 years

Do you have any allergies that you are aware of? If so, please elaborate.*

Please give details

Do you have any health issues that maybe effected by nutritional changes?*

Please give details

1. Introduction

This Nutrition Coaching Waiver Form is an agreement between you ("Client") and Dave Brockway Nutrition Coaching, part of the services provided by Dave Brockway. By signing this Waiver, you agree to the terms outlined herein and acknowledge the inherent risks and benefits associated with participating in nutrition coaching sessions.

2. Nature of the Service
Nutrition coaching involves personalized advice aimed to meet your dietary and health goals. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider regarding any medical condition.

3. Assumption of Risk
You acknowledge that nutrition coaching may involve recommendations on diet adjustment that could impact your health. By agreeing to these terms, you assume the responsibility for these risks, both known and unknown, even if arising from the negligence of Dave Brockway Nutrition Coaching and its affiliates.

4. Release and Waiver of Liability
By signing this document, you release Dave Brockway Nutrition Coaching and its officers, employees, and agents from all liability, claims, and expenses that may arise from injury or harm to you, or from damage to your property in connection with participation in the nutrition coaching program. This release includes, but is not limited to, personal injury, illness, death, and property damage, except to the extent that these were caused by the gross negligence or willful misconduct of Dave Brockway Nutrition Coaching.

5. Client Responsibilities
As a client, you agree to disclose honestly your dietary, medical history, and other health-related information. You commit to following the recommendations and plans as discussed and agreed upon with your nutrition coach. You understand that failure to comply with these guidelines may diminish the possible outcomes of the program.

6. Confidentiality
All information shared by you during the course of your nutrition coaching will be kept confidential by Dave Brockway Nutrition Coaching. Information will only be disclosed with your written consent or as required by law.

7. Termination of Services
You or Dave Brockway Nutrition Coaching may terminate the coaching services at any time. Upon termination, any outstanding payments must be settled, and you will cease to use any proprietary materials provided during the sessions.

8. Consent to Treatment
I consents to receive nutrition coaching services from Dave Brockway Nutrition Coaching and its nutrition coaches, understanding that they have the right to refuse or modify recommendations at any time.

9. Acknowledgment
By signing this Waiver, you affirm that you have fully understood the nature of the nutritional coaching services and the risks involved. This agreement remains in effect for the duration of your participation in any nutrition coaching sessions with Dave Brockway Nutrition Coaching.

I have read, understood and accurately completed this questionnaire & . I confirm that I am voluntarily engaging in a nutritional coaching.*

NameDate

Signature*

I have read, understood, and accepted the rules for Waiver + Service Terms & Conditions

Nutrition New Clients Needs Analysis

Nutritional Coaching Waiver + Service Terms & Conditions