Fitness and Nutrition Questionnaire

Keslie B Fitness

Group Coaching Intake, Consent, and Waiver
General Information
Full Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Age
years
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Baseline Measurements
Height
Weight
Health / Medical History

Do you suffer or have suffered from any of the following conditions?
Heart Disease
Stroke
Cancer
Diabetes
Asthma
High Blood Pressure
Seizures
High Cholesterol
Difficulty Hearing
Difficulty Seeing
Joint or Mobility Concerns
Neuromuscular Disease
Back, Knee, or Hip Pain
Nerve issues in Neck, Hands, or Feet
If yes to any of the above options, please describe below:
Please list any other serious illness, operations, or accidents you have had in the past (list dates).
Please list any supplements or medications you are currently taking.
Lifestyle
Smoking?
Ex-Smoker?
If yes, how many packs per day?
Alcohol?
If yes, how often? Daily / Weekly / Monthly?
Exercise
List your current workout routine:
What are your exercise goals?
What are your biggest struggles/concerns for engaging in regular physical activity?
List any physical activities you enjoy doing:
Nutrition
Dieting history:
What are your nutrition goals?
What are your biggest struggles/concerns with food?
Daily Schedule and Activity:
I, First Name* Last Name* have provided the correct information above regarding my health and lifestyle, and I am fully able to participate in physical exercise. If I am not, I will inform my coach and be
seen by a licensed health provider and receive written clearance when able to participate. I fully understand that I am participating in a program that may involve strenuous physical activity including, and not limited to, strength and endurance training, cardiovascular conditioning, and various other fitness activities.
In consideration of my participation in this exercise and/or nutrition program, I, First Name* Last Name* hereby release Keslie B Fitness, LLC and any of her agents from any demands, claims, and actions as a result of my
participation. I am fully aware the Keslie B Fitness programs are created from professional education, certification, and experience, as well as, current practices, and evidence-based health expertise. I will not hold Keslie liable for any injury incurred during participation. Injuries may include, and are not limited to, muscle strains, muscle tears, muscle pulls, heart attacks, broken bones, shin splints, heat prostration, injuries to knees, back, foot, arm, neck, ligaments, joints, or any other soreness, injury and illness, including death.
In consideration of my voluntary action to consume foods through nutrition coaching and education, I,First Name* Last Name* hereby release Keslie B Fitness, LLC and any of its agents from any demands, claims, and actions as a result of my participation. I am fully aware Keslie B Fitness is a certified Sports Nutrition Specialist and not a registered dietician or physician, and that her programs are created from personal and professional experience, current best practices, and evidence-based health expertise. I will not hold Keslie B Fitness, LLC liable for any injury or illness incurred during participation, as I have the choice on what healthy foods to consume to the best of my knowledge. Injuries may include, and are not limited to, food sensitivity or allergy, swelling of the throat, tongue, or airway, choking, and death.
I HEREBY AFFIRM THAT I HAVE THOROUGHLY READ AND COMPLETELY UNDERSTAND THE ABOVE STATEMENTS. By signing below I am committing to the group coaching program for it's entirity. I fully understand reimbursment will not be provided upon signing up for group coaching.
Participant Name (Print) First Name* Last Name*
Participant Signature
Date

MonthDayYear
Date
Age
Should be Empty:

Keslie B Fitness

General Information

Baseline Measurements

Health / Medical History

Lifestyle

Exercise

Nutrition