Name:*Date*Email*Do you describe yourself as Vegan, Vegetarian or Omnivore? If Vegan/Vegetarian, how long for?Health History Please check all boxes that apply to youAcne Past Present ADD/ADHD Past Present Addiction (alcohol or drugs) Past Present Allergies Past Present Anaemia Past Present Anxiety Past Present Arthritis Past Present Asthma Past Present Bladder Infections Past Present Bloating/Gas Past Present Blood Sugar Problems Past Present Bronchitis Past Present Cancer Past Present Celiac Disease Past Present Colds or Flue (frequent) Past Present Cold Sores Past Present Chronic Fatigue Past Present Constipation Past Present Depression Past Present Diabetes type 1 Past Present Diabetes type 2 Past Present Ear Infections Past Present Eczema Past Present Emphysema Past Present Fainting Past Present Gall Bladder Problems Past Present Gout Past Present Hair loss or poor hair growth Past Present Headaches Past Present Heart Disease Past Present Heartburn, Acid Reflux Past Present Haemorrhoids Past Present Herpes Simplex Past Present High blood pressure Past Present High cholesterol Past Present HIV Past Present Hot flushes Past Present Hypoglycaemia Past Present Insomnia Past Present Intestinal problems Past Present Kidney stones Past Present Liver problems Past Present Nails, poor growth Past Present Nails, white spots Past Present Osteoporosis Past Present Panic Attacks Past Present Parasites Past Present Pregnant/Nursing mother Past Present Psoriasis Past Present Respiratory problems Past Present Ring in ears Past Present Seizures Past Present Severe mood swings Past Present Skin conditions Past Present Spider veins Past Present Stroke Past Present Thyroid condition Past Present Varicose veins Past Present Yeast infection Past Present Are there any other conditions that you would like to list?Are you allergic to anything? If so, list below:DIET REVIEW Describe a typical day’s meals (include all foods/drinks consumed. Be as specific as you can)Breakfast:Usual Time:Lunch:Usual Time:Dinner:Usual Time:Snacks:Usual Time:Do you crave? (check all that apply) Sugar/Sweets Savoury Bread Milk Meat Alcohol What are your favourite foods?What foods do you strongly dislike?Do you take any medications, antibiotics, nutritional supplements or vitamins? If so, please list.Are you sensitive to any of the following? Gluten Dairy Soy Nuts Other If other, please list:Occupation:Work Hours:Do you exercise? If yes, what kind?How frequently do you exercise? (duration of session as well and times per week)Daily Energy level: Excellent Good Fair Poor Daily Stress level: Very High High Fair Poor N/A Body Weight:Body Fat % (if known)Height:What are you health and fitness goals? (Circle all that apply to you) Lose body fat Build lean muscle Become healthier as a whole Any other information that you think is relevant that you would like to share?Waiver and Release of Liability I agree and understand that during and after participating in coaching from Vegan Fitness Academy. I understand that Vegan Fitness Academy provides no guarantee or assurances that through nutrition counselling. I assume all responsibility and any risks associated with the nutritional choices that I make. I agree to hold Vegan Fitness Academy and its counsellors harmless and release them from any liabilities associated with recommendations and information given by them to me relating to dietary changes or nutritional supplements. I specifically recognize and agree that I have been advised by Vegan Fitness Academy that dietary changes and/or the taking of nutritional supplements may have differing effects on individuals. I understand that with respect to changes in my diet or in my nutritional practices it is recommended that I consult with my physician. I understand that the nutritional counselling provided is not considered to be medical advice and that I am encouraged to continue to pursue medical care with my health care provider. Having read and understood the above statements and having had the opportunity to ask questions regarding the meaning and effect of this Waiver and Release of Liability, Privacy Practices & Payment Terms & Policy, my signing is voluntary. I agree with the above terms. (enter your name below)*Client’s Signature (or signature of guardian)*DateCAPTCHA
