Nutrition and Wellness Coaching Consent FormKetogenic Living -- Healthy Fats Healthy Life Disclaimers I understand that KT Keto Coaches are Ketogenic Living Certified Coaches and do not dispense medical advice nor prescribe treatment. Rather, they provide education to enhance my knowledge of health as it relates to foods, behaviors associated with eating, and exercise. While nutritional support can be an important complement to my medical care, I understand ketogenic nutrition counseling is not a substitute for the diagnosis, treatment, or care of disease by a medical provider. If I, the “CLIENT”, am under the care of a healthcare professional and/or am currently using prescription medications, I should discuss any dietary changes or potential dietary supplement use with my doctor, and should not discontinue any prescription medications without first consulting with my doctor. I acknowledge that the advice I receive during my ketogenic nutrition coaching sessions is separate from the care that I receive from any medical facility, and that this coaching is in no way intended to be construed as medical advice or care. I should continue regular medical supervision and care by my primary care physician. Personal Responsibility and Release of Health Care Related Items I acknowledge that I take full responsibility for my life and well-being, as well as the lives and well-being of my family and children (where applicable), and all decisions made during and after the duration of my participation in ketogenic coaching. I expressly assume the risks of ketogenic nutrition coaching, including the risks of trying new foods, and the risks inherent in making lifestyle changes. I release Ken Christensen, Tina Christensen, and any other KT Keto Coaches, and KT Keto, from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which I ever had, now have, or will have in the future against Ken Christensen, Tina Christensen, or any KT Keto coach, or KT Keto, arising from my past or future participation in, or otherwise with respect to, the nutrition sessions, unless arising from the gross negligence of a KT Keto coach. Confidentiality KT Keto Coaches will keep my information private, and will not share my information to any third party unless compelled to by law or with my consent. Payments and Refunds Payments are due at the time of service and there are no refunds for payments made to KT Keto, unless an issue of gross negligence of KT Keto, or KT Keto coaches arises. Arbitration, Choice of Law and Limited Remedies In the event that there ever arises a dispute between KT Keto Coaches and/or KT Keto and myself (“CLIENT”) with respect to the services provided pursuant to this agreement or otherwise pertaining to the relationship between the parties, the parties agree to submit to binding arbitration before the American Arbitration Association (Commercial Arbitration and Mediation Center for the Americas Mediation and Arbitration Rules). Any judgement on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Such arbitration shall be conducted by a single arbitrator. The sole remedy that can be rewarded to me, the “CLIENT”, in the event that an award is granted in arbitration is refund of the PROGRAM FEE. Without limiting the generality of the foregoing, no award of consequential or other damages, unless specifically set forth herein, may be granted to me, the “CLIENT”. This agreement shall be construed according to the laws of the State of Indiana. In the event that any provisions of this Agreement are deemed unenforceable, the remaining portions of the Agreement shall remain in full force. I further agree that by typing my name twice below, the second time in all capital letters, that this is equivalent to my signature to facilitate an electronic agreement.Name *Signature *Don't forget to do ALL CAPS!Personal InformationFirst Name *Last Name *Phone Number *Email Address *AgeBirthdayGenderMaleFemaleHeightEnter the number of feet tall you are... there's a place for inches!HeightEnter the number of additional inches you are over the feet to the left!Body Fat 115 to 19%35 to 39%Body Fat 220 to 24%40 to 44%Body Fat 325 to 29%45 to 49%Body Fat 430 to 34%50% and upBody Fat 115 to 19%35 to 39%Body Fat 220 to 24%40 to 44%Body Fat 325 to 29%45 to 49%45 to 44% should be to 49%!!Body Fat 430 to 34%50% and upCurrent Weight in PoundsGoal Weight in PoundsWeight One Year Ago, in PoundsLifestyle.How many hours of sleep per night?Do you exerciseYesNoCardio Days Per Week1234567Weights/Resistance Days Per Week1234567High Intensity Interval Training (HIIT) Days Per Week1234567Do you drink alcohol?YesNoHow much alcohol do you drink?Every DayWeek DaysWeekendsSpecial OccasionsDo you smoke cigarettes?YesNoHow often do you smoke?More than 1 pack a dayOne pack a dayOne pack every other dayTwo packs per weekOne pack per weekOne cigarette per dayDo you do recreational drugs?YesNoWhat drugs, and how often?Children?YesNoChildren's AgesWhat is your family living situation?SingleMarriedSeparatedDivorcedDivorced - RemarriedWidowedWidowed - RemarriedWhat do you do for work?What do you do for fun?On a scale of 1 to 10, where 1 is least stress, and 10 is the most, what is your current level of stress?12345678910What is the cause of your stress?Have you had any recent life changes or big events?YesNoPlease describe your life changes or big events.Health HistoryCurrent MedicationsDid you take antibiotics a lot as a child?YesNoDo you have a bowel movement at least once per day?YesNoHave you ever been diagnosed with IBS or GERD?YesNoAre you diabetic?YesNoDo you have any hormonal issues?YesNoDo you have any thyroid issues or concerns?YesNoWhat are those thyroid issues or concerns?Is your period regular?YesNoHave you ever or do you currently suffer from depression or anxiety?YesNoHave you had any injuries?YesNoPlease list all surgeries:Do any chronic diseases run in your family?YesNoWhat are those chronic diseases?Do you have any other health concerns or conditions?FoodDo you have any food allergies?YesNo / None knownPlease keep in mind you may be eating foods you've never eaten before, so be alert!Food allergies:Favorite food?Foods you do not like?Do you emotionally eat?YesNoDo you eat out of boredom?YesNoWhat does a typical day of eating look like for you?What do you like to order when dining at a restaurant?How many glasses of water per day do you drink?012345 or moreFor the sake of consistency, assume an 8oz. glass.It's all about YOU!What are your health goals and aspirations?Why are these goals and aspirations important to you?You've made it!Now all that's left for this part of your journey is to submit this form.On your mark, get set, GO!!Send Message