KneticRx Athletic Club x Restoration Therapy

Restoration Therapy
Tailored Support for Your Restoration Therapy Goals

Thank you for completing this questionnaire! Your responses will help us tailor a personalized restoration therapy plan that aligns with your medical history, lifestyle, and recovery goals. Expect a follow-up via email, call, or text—whichever you prefer. This next step is essential in starting your journey toward improved mobility, pain relief, and overall well-being.
How do you prefer to be contacted?*

EmailCallText
Who is your trainer?*
(i.e. Trainer Name, Team Member)
Personal Information
Name*

First NameLast Name
Age*
Gender*

FemaleMaleNon- binary
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for your visit? (Select all that apply)

Nutrition AssessmentMeal PlanNutrient Analysis (Calories, Macros, etc.)Lifestyle ChangesNutritional Counseling
What form of preferred payment would you be able provide for service?*

Cash PayInsurance (If Provider is in network)Care CreditHSA
Medical History and Nutrition Questionnaire
Please indicate whether you have been diagnosed with any of the following diseases or symptoms

AnemiaAnxiety or Panic AttackArthritis (osteoarthritis or rheumatoid)AsthmaBronchitisCancerChronic Fatigue SyndromeDiabetes: Type IDiabetes: Type IIPrediabetesGestational DiabetesEczemaEpilepsyFibromyalgiaFungal InfectionGoutHeart AttackHeart diseaseHepatitisHigh blood fats (cholesterol, triglycerides)High blood pressure (hypertension)Hypoglycemia (low blood sugar)Other
Provide further information if any
How often do you skip meals?*

DailyOccasionally (a few times a week)Rarely (a few times a month)Never
Do you have any food allergies or intolerances? If yes, list below
Do you take any supplements or vitamins? If yes, list below
Please select the physical activities you are involved often*

Stretching/YogaCardio/AerobicsStreght-trainingSports or LeisureNoneOther
List any recent or relevant medical work or lab results:*
Current medications, over-the-counter drugs, and supplements (Please include name, dosage, and frequency for each)*
Any gastrointestinal (GI) distress? (If yes, please describe)*
Anthropometrics:
Lowest Weight:*
Highest Weight:*
Diet & Food Habits:
Are you active?*
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)*
Eating, Self-perception, and Past (ESP):
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)*
Our Terms and Conditions
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.
Release of Information Consent
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:

- We are legally required to disclose your information, regardless of consent;

- It is unreasonable or impractical to obtain consent, or consent has been refused; or

- 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.

Date*

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Date
Signature*

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Restoration Therapy

Tailored Support for Your Restoration Therapy Goals

Personal Information

Medical History and Nutrition Questionnaire

Anthropometrics:

Diet & Food Habits:

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

Our Terms and Conditions