My Name is:
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First Name
Last Name
Who is this Intake Form for?
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Date of birth:
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Height
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Weight
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Phone
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Eat For Health may call clients in the USA prior to the coaching session to clarify details or scheduling.
Country
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What would you like for me to help you with during our coaching session?
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What present conditions, diagnoses, or symptoms do you have?
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Please select all that apply.
Out of all your conditions, which one(s) would you say is the most concerning to you?
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What diets have you tried in the past?
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Please tell us what your curent diet is like. What do you normally eat for meals / snacks / desserts?
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Writing as much detail as possible will help our coaching session
What vitamins or supplements are you taking?
What over the counter drugs are you taking?
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If none, please write "None."
What prescription drugs are you taking?
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I eat pre-packaged microwave meals:
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I eat restaurant foods:
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I eat dessert:
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I eat pasta, bread, or rice:
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I eat pizza or fries:
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I cook my own meals from scratch
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Beverages
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Please check all that apply
Bowel Elimination
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(Non-menopausal females only) Date of last period. Please describe your mensural cycles. How long do they normally last / How often? / Abnormal pain / Abnormally heavy? / Anything else?
(Females only) I have been in menopause since the following date
How did you hear about us?
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Personal invitation
A friend
In-person booth / local event
At church
An Eat For Health group event
An email
Social Media
Internet Search
Other
Any other details you want to share?
Liability Waiver
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TERMS OF SERVICE AND WAIVER OF LIABILITY
Arnah Rudicil MHP, NNP is not a physician or psychologist, and the scope of her coaching services does not include diagnosing specific illnesses, prescribing, or de-prescribingmedications. Any change to prescriptions or dosages is a decision the client must make with his or her physician.
If you suspect you may have an illness that may require medical attention, you are encouraged to consult with a licensed physician without delay.
Arnah Rudicil MHP, NNP, Eat For Health LLC and its participants (hereinafter referred to as “EFH”) cannot be held liable for any medical information or advice given by EFH or insinuated as medical advice from EFH.
Clients and caretakers are expected to use their best judgment, along withtheir medical provider before implementing recommendations given by EFH,including but not limited to coaching sessions, phone conversations, texts, emails, or written materials. No information obtained by EFH clients should be considered a substitute for professional medical advice, diagnosis, or treatment.
I, the client, accept full responsibility to disclose any food allergies, intolerances, or dietary restrictions. I understand that EFH is not responsible for allergic reactions or medical complications resulting from, but not limited to, my failure to disclose or effectively manage such conditions.
I, the client, understand that although Arnah Rudicil MHP, NNP and Eat For Health LLC and its participants may be aware of my past and present prescriptions, vaccinations, and over-the-counter drug use, they do not bear responsibility for drug-related interactions or side-effects.
I agree that if I am receiving coaching or general health advice from EFH on behalf of another, that I am the parent or legal guardian of that individualor that said individual will sign their own form and be present for the coaching session.I also agree that if I implement any suggested services for the general or nutritional health of another individual who is over the age of eighteen (18), that I have an active Health Care Power of Attorney (HCPOA) for that individual if required by law.
I understand that EFH coaching sessions are not medically supervised, and that I or my medical provider or the participant’s medical provider, am/are fully responsible for all medical care. If any client, parent, or caretaker has any questions regarding information given by EFH and its impact on their health, they agree to consult with a qualified medical/health provider before proceeding.
I, client, parent, or caretaker, agree that I and my physician (or the physician(s) of the person for whom I am caretaker or legal guardian) am/are in all instances responsible for my/their medical care.
If I, (the client, my child, or the person for whom I am a caretaker) am diabetic, and implement Keto, Therapeutic Carbohydrate Restriction (TCR), Intermittent Fasting (IF) and/or prolonged fasting, on the advice of EFH, then I agree to assume full responsibility for monitoring my/their blood sugars very closely and to work with a licensed physician to adjust my/their medications as needed. I agree to hold EFH harmless from any medical implications arising from implementing any suggested dietary changes that may cause complications or death from any preexisting medical condition.
I understand that the service provided by EFH may involve dietary changes, physical health recommendations, and other health related suggestions that carry inherent risks, including but not limited to allergic reactions to foods or ingredients, digestive discomfort or food sensitivity, physical, emotional or medical side effects from changes in diet or nutrition, or inaccurate health tracking due to self-reported information. I voluntarily assume all risks, known and unknown, associated with participation in these services. I waive my right to take legal action against Arnah Rudicil MHP, NNP or EFH should any harm, loss, or worsening of symptoms occur.
I agree that this release of liability applies to all communications with EFH or its members including but not limited to: individual or group coaching, group sessions, in-person, virtual, written, spoken, and electronic. I agree that EFH and the facility or platform hosting any in-personeventshall not be held liable for any injury or harm due to an EFH session or event. I also agree to hold EFH and its members harmless therefrom any injury occurring from consuming food or other products recommended or served by EFH or its members. I waive my right to take legal action against Arnah Rudicil MHP, NNP andEFH, and any of its members. I affirm that Arnah Rudicil MHP, NNP and EFH shall not be liable for any loss or injury due to health and nutrition information or ideas given.
I agree that various features of these terms of service may require payment. I agree to pay applicable fees for any service received by EFH. I agree that these payments are non-refundable, except as required by law, and that EFH’s pricing is subject to change atany time.
I understand that EFH may reach out to potential clients through the contact phone number or email address provided above to schedule my coaching appointment, and to clarify any questions concerning my health situation. I consent to being contacted for this purpose. I understand that EFH will never disclose any of my above information and commits to keepingall my voluntarily given medical information confidential. By signing my name herein, I take full responsibility for the above information, or if I am submitting this form on behalf of someone else, I hereby affirm that I am their legal parent or legal guardian, or that I have the express knowledge andfully-informed consent of the client named above.
I agree not to use EFH services for any unlawful purpose, including but not limited to interfering with or disrupting with the platform, posting false, harmful, or infringing content. EFH reserves the right to suspend or terminate any client’s account or access to our services without notice for violating any terms of service. I agree that Arnah Rudicil MHP, NNP and EFH have the right to deny my application for service at their discretion and for any reason, or to refer me to a different practice. I understand that EFH will act in good faith and use their best judgment when applying this provision.
I agree that all content, trademarks, logos, software, and services are owned by EFH or its members, and I may not reproduce, distribute, or modify their content without prior written permission. I further agree and acknowledge that EFH services may contain links to third-party websites or services. EFH is not responsible for the content or practices of those third parties.
Health and wellbeing are extremely personalized experiences, and therefore Arnah Rudicil MHP, NNP and EFH will always strive to bring you the best, most effective methodologies, and recommendations within their scope of practice. However, I, the client, agree that EFH services are “as is” and that EFH makes no guarantees of any kind about the accuracy or effectiveness of their content. EFH disclaims all warranties, either express or implied and is not liable for any direct, indirect, incidental, or consequential damages which may occur from using our services. This provision is applicable to the fullest extent permitted by law.
I agree to indemnify, defend, and hold harmless EFH and its members from any claims, damages, losses, or death incurred from use of its services. I also agree that EFH is a limited liability company and governed by the Ohio Revised Code Limited Liability Act. Any member of an LLC is not personally liable, solely by reason of being a member, for a debt, obligation, or liability of an LLC, whether arising in contract, tort, or otherwise, or for the acts or omissions of any member, agent, or employee.
To the fullest extent permitted by law, I hereby release, waive, discharge, and hold harmless EFH, its owners,employees, agents,volunteers, members,and affiliates from any and all liability, claims, demands, damages, losses, injuries or causes of action arising out of or related to participation in EFH services,the use of any products or material provided by EFH, and any acts or omissions, negligent or otherwise, by EFH or its representatives. This release includesany claims based on the negligence of EFH and its affiliates, except where prohibited by law.
These terms are governed by the laws of the State of Ohio. By signing this agreement, I acknowledge that the laws of the State of Ohio will govern any action or dispute arising from this agreement or any service provided by EFH.
EFH reserves the right to update these terms at any time. EFH will notify users of any material changes by email or posting notice on this website. Continued use of service after changes are implementedwill be implied verification of user consentofacceptance of the updated terms of agreement.
I UNDERSTAND AND ACKNOWLEDGE THAT EFH MAKES NO GURANTEES OR WARRANTIES REGARDING ANY SPECIFIC HEALTH, WEIGHT LOSS, OR FITNESS OUTCOMES FROM USE OF ITS SERVICES.
I ACKNOWLEDGE BY SIGNING THIS AGREEMENT THAT EFH AND ITS MEMBERS ARE NOT MEDICALLY LICENSED PROFESSIONALS, AND THAT ANY SUGGESTIONS OR ADVICE GIVEN BY EFH OR ITS MEMEBRS ARE NOT A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS OR TREATMENT
THE CONTENT PROVIDED BY EFH IS FOR THE PURPOSE OF SUGGESTING IMPROVEMENTS TO ONE’S OVERALL HEALTH THROUGH DIETARY MEASURES AND IS NOT A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS OR TREATMENT. YOU SHOULD ALWAYS CONSULT A QUALIFIED HEALTHCARE PROVIDER BEFORE STARTING A NEW DIET OR NUTRITIONAL BASED PROGRAM, ESPECIALLY IF YOU HAVE A KNOWN PRE-EXISTING MEDICAL CONDITION.
In addition to my own signature, if I am completing this form on behalf of another, I am placing THEIR name below, signifying that I agree to all the terms or service and waiver of liability provision stated herein on their behalf:
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My electronic signature:
First Name
Last Name
If this form was completed on the behalf of another, please type THEIR name below:
First Name
Last Name
Today's Date
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