Nutritional Assessment and History Form

Your Name:*
Your Email:*
How often do you check email?
Your Street Address:*

Telephone:

Work:
Home:
Cell:
Age:

Height:

Feet:
Inches:

Date of Birth:

Month:
Day:
Year:
Current Weight:
Weight six months ago:
Weight one year ago:
Would you like your weight to be different?
Explain why/why not:
Relationship Status:
Children?
Occupation:
Hours per week:
Do you sleep well?
Do you wake up at night?
What times?
To Urinate?
What time do you generally get up in the morning?
Constipation/Diarrhea?
What blood type are you?
What is your ancestry?
Women: Are your periods regular?
Women: How many Days is your flow?
Women: Painful or Symptomatic?
Women: Explain above
Do you take any supplements or medications? If so, which?
Are there any healers, helpers or therapies with which you are involved?
What role does exercise play in your life?
Do you drink coffee, smoke cigarettes, or have any major addictions?
What percentage of your food is home cooked?
Where do you get the rest from?
Serious illness/ hospitalizations/ injuries?
What is your chief concern?
How is the Health of your Mother?
How is the Health of your Father?
PART TWO
What foods did you eat often as a child?
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
What about one year ago?
Breakfast (one Year ago)
Lunch:(one Year ago)
Dinner:(one Year ago)
Snacks:(one Year ago)
Liquids:(one Year ago)

Currently?

Breakfast (Currently)
Lunch:(Currently)
Dinner:(Currently)
Snacks:(Currently)
Liquids:(Currently)
Service Purchased:
Other, please list:

Client Acknowledgement and Assumption of Risk and Full Release from Liability for TotalBodyFit LLC:

Client acknowledges that these physical activities involves the inherent risk of physical injury or other damages including but not limited to heart attacks, muscle strains, pulls or tears, and any other illness or injury caused occurring during or after client’s participation in the therapy. Client further acknowledges that such risks include but are not limited to injuries caused by the negligence of the therapist or other person, defective or improperly used equipment, slip and fall by client, or an unknown health problem of the client. Client affirms that client is in good physical condition and does not suffer from any disability that would prevent or limit participation in the therapy. Client agrees that it is the responsibility of client to seek competent medical or other professional advice regarding any concerns or activities. By signing the agreement, client asserts that he or she is capable of participations in the physical activities.

Please initial here:

Notice: Client, on behalf of client, his or her heirs, assigns and next of kin agree to fully release TotalBodyFit LLC (as well as any of its owners, employees, or other authorized agents including independent contractors) from any and all liability, claims, and/or litigation actions that buyer may have for injuries, disability or death or other damages of any kind including but not limited to punitive damages arising out of participation in TotalBodyFit LLC services including but not limited to massage therapy even if caused by the negligence, gross negligence, intentional acts or omissions and/or any other type of fault of TotalBodyFit LLC, its owners, employees, or other authorized agents including independent contractors.

Enter full name here as your electronic signature and acceptance of above terms:

Signature:

Date Signed (required)

Month (xx):
Day (xx):
Year (20xx):

All bookings require 24 hours advance booking and credit card guarantee. A full price of the treatment will be charged to your credit card for appointments that are rescheduled or cancelled less than 24 hours.


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