Metabolic Reset Profile Form

PERSONAL PROFILE
Name, address and phone number of family
Coach Name*
Jennifer Dean, ID#: 52964
physician (or primary health care provider):
Metabolic Balance GmbH & Co KG is unable to create meal plans for pregnant women, nursing mothers, patients with severe renal or hepatic insufficiency, cancer patients with active cancer and/or undergoing cancer treatment or people whose BMI is *
A Personal information

Mr.Mrs.
Last name
Name

First nameLast name
(DD.MM.YYYY)
Address
Date of birth1

MonthDayYear
Date
Date of birth1

MonthDayYear
Date
Postal Code
City / Province
Phone number | Cell phone
E-mail
example@example.com
Occupation
kg/lbs
kg/lbs
Height1
Weight1
Goal weight1
cm/in
cm/in
cm/in
B How did you find out about Metabolic Balance®?

TVInternetNewspaper / MagazineCoach promotionRecommendationRecommended by
Other
C) Declaration of consent in accordance with data protection legislation
GmbH & Co. KG. Furthermore, I agree that such data is being used to grant my participation in the Metabolic Balance® program and create my individualized meal plan. Consent

I agree that my coach may communicate my data such as my personal information about my health and food preferences as well as my blood values to Metabolic BalanceWhen it comes to sharing my data, as indicated above, to Metabolic Balance GmbH & Co. KG to grant my participation in the Metabolic Balance® program and create my
is voluntary and can be withdrawn at any time upon further notice. It is, however, not possible to participate in the Metabolic Balance® program without first giving this consent.
individualized meal plan, I discharge my coach from their duty of confidentiality provided they are required to comply with such duty of confidentiality. Consent is voluntary and

can be withdrawn at any time upon further notice. It is not possible, however, to participate in the Metabolic Balance® program without first giving this consent.
Your coach is the party responsible for processing your data (controller Metabolic Balance GmbH & Co.KG (Bgm.-Hallwachs-Str.8, 84424 Isen, Germany) acts as a data pro cessor within the framework of your contract with your coach and processes the transmitted data exclusively on your coach’s instructions. After creating the meal plan, Metabolic Balance GmbH & Co. KG shares it with your coach. Your coach can access the above-mentioned data and the meal plan via our Coach Portal to provide you with comprehensive

advice as part of your participation in the Metabolic Balance® program. The use of your data for participating in the Metabolic Balance® program is based on GDPR Art. 6, paragraph 1, item a as well as on GDPR Art. 9, paragraph 2, item a. We will continue to process your data for the duration of your contract with your coach to participate in the Metabolic Balance® program. According to GDPR Art. 28, your data may be processed on our behalf by technical service providers. In such cases, we ensure that the processing of personal data is carried out in agreement with the GDPR provisions. If your data is processed then you have the right to obtain information about the data that we store about you (GDPR Art. 15 If inaccurate personal data is processed then you have a right to rectify it (GDPR Art. 16 If permitted by law, you may demand your data to be deleted or its processing to be restricted. (GDPR Art. 17 and 18 You also have the right to notify us about your data as well as the right to have it transferred (GDPR Art. 19 and 20 Irrespective of the foregoing, you also have the right to file a complaint about the processing of your data with a data protection supervisory authority. If you wish to exercise your rights, please contact your coach.

You will find further information on the Metabolic Balance website www.metabolic-balance.com.
Date

MonthDayYear
Date
City
Signature*

Clear
As of 06/08/2024 | © Metabolic Balance GmbH & Co. KG | EN_CA
PERSONAL PROFILE 2
Client‘s Name

Cardiac insufficiencyJoint painAsthmaThyroid hyperfunctionVertigo / DizzinessSkin disordersMigraineThyroid hypofunctionDiabetesHigh blood pressureGluten intolerance / AllergyLactose intoleranceD Information on health and medical historyOther, e.g. sleep disturbance, depression, digestive issues
D Information on health and medical history
Pregnant / Nursing

NoYe s
Allergies

NoYe s
which ones
Ye s

Noto treat
Ye s

Blood lipidsUric acidDiabetesThyroidAntipsychoticsHeartwhich onesOther (e.g. Contraceptive / Hormone replacement)
Other (e.g. Contraceptive / Hormone replacement)
Blood draw

NoYe s
Date

MonthDayYear
Date
E Information on food consumption / Eating habits as well as food allergies max. 4 check marks

I eat everything
I seldom eat

MeatPoultryFishCheeseI refuse to eatE Information on food consumption / Eating habits as well as food allergies max. 4 check marksSeafoodSoyOther (e.g. Contraceptive / Hormone replacement)Date
I anticipate F With Metabolic Balance

Weight lossWeight maintenance
Please fast 12 hours before blood drawing - only pure water is allowed, do not eat or drink anything else! However, your prescribed medication needs to be taken as per your doctor‘s indication.

Medical Disclaimer: Metabolic Balance® is not a medically supervised program. The Metabolic Balance® plan and system is designed to help individuals

lose weight and achieve a new lifestyle. It is a meal planning program only and in no way represents a medical treatment or medical advice. The program does not constitute a medical product or service and does not diagnose or treat any medical condition or disease. It does not accommodate for physical or medical conditions, food allergies or the taking of any medications. All medical conditions and your current health status should be discussed with your physician prior to beginning this, or any other, weight loss program.
Client Initials
As of 06/08/2024 | © Metabolic Balance GmbH & Co. KG | EN_CA
Should be Empty:

PERSONAL PROFILE

PERSONAL PROFILE 2