Carly Nelson Nutritionist & Lifestyle Coach
Carly Nelson
Nutritionist/Lifestyle Coach
It's not a diet .. it's a lifestyle!
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New Client Information & Agreement Form
Release of Liability & Privacy Policy

By checking "Yes" in the  "I Agree Box",  at the bottom of this form, I hereby agree to expressly assume and accept any and all risks of injury or death that I may suffer, and hereby irrevocably release Carly Nelson her agents, officers and employees from any liability with respect to these risks while participating in a health and wellness program.  If in doubt after completing this questionnaire, please consult your doctor prior to physical activity. I accept these policies as they relate to nutritional counseling services with Carly Nelson and policies regarding personal information.

Please telephone Carly at 727-243-5256 (Eastern) to discuss payment details. Carly will answer any questions or concerns and you may then complete the form below and Submit to Carly.
You will then proceed to the INITIAL NUTRITION ASSESSMENT FORM


required field = Required
Date: (mm/dd/yy) required field
Gender: male female required field
1. Name:
required field
2. Address:
required field
3. City:
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4. Prov./State
required field
5. Country:
required field
6. Postal/Zip Code:
required field
7. Home Phone:
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8. Cell Phone:
9. Business Phone:
10. Occupation:
11. Employer:
12. Date of Birth (mm/dd/yy):
required field
13. Personal Email Address:
required field
15. Name of your family doctor:
required field
16. Doctor's phone number:
required field
17. Your last physical (mm/dd/yy):
required field
18. Briefly describe your medical history:
required field
19. Please list any medications, vitamins or supplements you take:
required field
20. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes No required field
21. Do you feel pain in your chest when you do physical activity?
Yes No required field
22. In the past month, have you had chest pain when you were not doing physical activity?
Yes No required field
23. Do you lose balance because of dizziness or do you ever lose consciousness?
Yes No required field
24. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes No required field
25. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure and / or heart condition?
Yes No required field
26. Have you ever tested HIV positive?
Yes No required field
27. Have you ever been diagnosed with cancer?
Yes No required field
I agree to share this information with Carly Nelson.Yes required field

 
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