KNETIC Rx ATHLETIC CLUB x NUTRITION Rx

How do you prefer to be contacted?

Who is your trainer?

(i.e. Trainer Name, Team Member)

Name

First NameLast Name

Age

Gender

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reason for your visit? (Select all that apply)

What form of preferred payment would you be able provide for service?

Please indicate whether you have been diagnosed with any of the following diseases or symptoms

Provide further information if any

Current medications, over-the-counter drugs, and supplements (Please include name, dosage, and frequency for each)

Do you take any supplements or vitamins? If yes, list below

List any recent or relevant medical work or lab results:

Are you active?

Please select the physical activities you are involved often

Height (inches):

Lowest Weight (lbs):

Highest Weight (lbs):

How often do you skip meals?

Which meal do you skip, if any?

Alcohol Consumption: (If yes, please specify frequency and amount)

Do you smoke? (Please indicate if you smoke or vape)

Do you drink caffeine? (If yes, please specify how often)

Do you have any food allergies or intolerances? If yes, list below

Any gastrointestinal (GI) distress? (If yes, please describe)

Are you satisfied with your food pattern?

Do you ever eat in secret?

Does your weight affect how you feel about yourself?

Do you currently suffer with or have you suffered in the past with an eating disorder?(If yes, please specify)

Please upload you MOST RECENT blood work, if applicable:

Please upload you Inbody or DEXA Scan, if applicable:

One's health and well-being are directly influenced by their nutrition and vice versa. By completing this form you accept that all mentioned information is correct and that you are accepting a treatment that is prepared based on the provided data. Any health condition occurred by a lack of information that is triggered due to the provided diet will be on customers' responsibility.

Nutrition Coaching & Dietitian Client Agreement

Nutrition Coaching & Dietitian Client Agreement&#13;&#10;&#13;&#10;KneticRx Athletic Club & Affiliated Providers&#13;&#10;&#13;&#10;This agreement ("Agreement") is entered into by and between the undersigned client ("Client") and KneticRx Athletic Club, including its partnered Registered Dietitians and nutrition service providers ("Provider"), and shall govern the terms and conditions of all nutrition consultations and services ("Services") rendered by the Provider.&#13;&#10;&#13;&#10;By signing below, the Client acknowledges, understands, and agrees to the following:&#13;&#10;&#13;&#10;1. Medical Disclosure and Risk Acknowledgment&#13;&#10;&#13;&#10;Client affirms that they have disclosed all known medical conditions, allergies, medications, or dietary restrictions that may impact their nutrition plan. Client understands that nutrition services are not a substitute for medical care, diagnosis, or treatment from a licensed physician.&#13;&#10;&#13;&#10;Client acknowledges that nutrition recommendations carry inherent risks, including allergic reactions, digestive issues, or unanticipated effects. Client releases KineticRx and its Providers from liability arising from such outcomes, unless due to gross negligence or misconduct.&#13;&#10;&#13;&#10;2. Appointment Booking and Attendance&#13;&#10;&#13;&#10;Appointments must be scheduled in advance. At least twenty-four (24) hours' notice is required for cancellations or rescheduling. Late cancellations or no-shows may result in the full consultation fee being charged. Late arrivals may shorten the session without reducing the fee.&#13;&#10;&#13;&#10;3. Payment Terms and Refund Policy&#13;&#10;&#13;&#10;Payment is due at the time of booking unless otherwise agreed in writing. Refunds are not offered after services are rendered. Dissatisfaction with results does not constitute grounds for a refund. Client feedback is always welcomed to improve future services.&#13;&#10;&#13;&#10;4. Client Conduct&#13;&#10;&#13;&#10;Clients are expected to maintain respectful and professional behavior throughout all communications and sessions. Any inappropriate or disruptive behavior may result in termination of the session and removal from future services.&#13;&#10;&#13;&#10;5. Provider Rights&#13;&#10;&#13;&#10;The Provider reserves the right to refuse or discontinue services if it is deemed unsafe, inappropriate, or in conflict with ethical or professional standards.&#13;&#10;&#13;&#10;6. Confidentiality&#13;&#10;&#13;&#10;All client records, intake forms, and health history will be maintained in strict confidentiality. Information will not be disclosed without client consent unless required by law. KneticRx staff with direct client involvement may access shared records to ensure coordinated care.&#13;&#10;&#13;&#10;Our Dietitian will work closely with KneticRx and its affiliates to coordinate the best support for you. This means your informed consent for sharing information will be sought and respected in all situations unless:&#13;&#10;&#13;&#10;We are legally required to disclose your information, regardless of consent;&#13;&#10;&#13;&#10;It is unreasonable or impractical to obtain consent, or consent has been refused; or&#13;&#10;&#13;&#10;The disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health, or safety of an individual or group of people.&#13;&#10;&#13;&#10;7. Policy Revisions&#13;&#10;&#13;&#10;KneticRx and its Providers reserve the right to revise this agreement and associated policies at any time. Clients will be notified if significant changes are made.&#13;&#10;&#13;&#10;8. Acknowledgment and Consent&#13;&#10;&#13;&#10;By signing below, the Client confirms they have read, understood, and voluntarily agreed to the terms of this agreement. The Client also confirms they have had the opportunity to ask questions before signing.

Date

Signature

Nutriton Rx

Personal Information

Medical History and Nutrition Questionnaire

Anthropometrics:

Diet & Food Habits:

Eating, Self-perception, and Past (ESP):

Upload Your Documents

Our Terms and Conditions