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CART
INTAKE FORM
CONSENT AND LIABILITY WAIVER
Name
Name
First Name
Last Name
Date of Birth
*
Date of Birth
MM
DD
YYYY
Weight
Height
Address
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Occupation
Physician
Physician's Phone
Physician's Phone
(###)
###
####
Have you ever been diagnosed with:
In an effort to effectively assist with nutritional planning, some basic health information is asked for within this form. This is voluntary information and you may refuse to fill out certain parts of this form, however, false or incomplete information may pose a threat to your health for which we cannot be responsible. Please feel free to contact us to clarify anything necessary in completing this form.
Heart Disease
High Blood Pressure
Hypertension
Cancer
HIV/AIDS
Diabetes
Are you:
Pregnant
On any medications
On any medical restrictions
Receiving medical treatment
Please explain any “Yes” questions here including dates:
*
Please list any other medical or health conditions not listed above that may require consideration in your participation in a weight-loss or fitness program including orthopedic:
*
Please describe your diet and an average day of eating:
*
Briefly describe your current level of activity and your health and weight goals:
*
Were you referred by a current client?
If yes, who?
By signing this intake form, I guarantee this information is true to the best of my knowledge and I agree to the above terms and conditions stated in the waiver.
Electronic Signature
Thank you!
