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
An email
Social Media
At church
A n Eat For Health group event
Internet Search
Other
Any other details you want to share?
Liability Waiver
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Release of Liability
Arnah Rudicil MHP, Eat for Health © and its participants are not acting in any professional capacity as your personal medical practitioner, and cannot be held liable for any medical information or advice given or insinuated. Arnah Rudicil MHP and Eat For Health © cannot give medical advice, diagnose or treat medical conditions, interpret medical results, prescribe or de-prescribe medications. Information given in Eat for Health is intended for general informational purposes only. Clients and caretakers are expected to use their best judgment, along with professional medical advice of their doctor, before implementing ideas given by Arnah Rudicil MHP in Eat For Health © coaching sessions, phone conversations, texts, emails, or written materials. Nothing obtained through these coaching sessions shall be interpreted as a substitute for medical advice.
I agree that if I am receiving Eat For Health © coaching or receiving health information from Arnah Rudicil MHP on behalf of someone else, that I am the parent or legal guardian of that individual.
If the client, parent, or caretaker have questions regarding information given by Arnah Rudicil MHP Eat for Health © and its impact on your health, please consult with a qualified health provider before proceeding.
I, the parent, client, or caretaker, agree that Eat for Health © coaching sessions by Arnah Rudicil MHP are not medically supervised events, and that I and my physician (or the physician(s) of the person for whom I am a caretaker or legal guardian) are in all instances responsible for my medical care, (for the medical care of the person for whom I am a caretaker/ legal parent or guardian).
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, I assume full responsibility for monitoring my blood sugars (or theirs) very closely and to work with a licensed physician to adjust my (or their) medications.
I waive my right to take legal action against Arnah Rudicil MHP or Eat For Health ©, should any harm, loss, or worsening of symptoms occur. I agree that this release of liability applies to all Arnah Rudicil’s communications: individual or group coaching, group sessions, in-person, virtual, written, spoken, and electronic. I agree that Arnah Rudicil MHP, and the facility or platform hosting the event, cannot be held liable for any injury or harm due to an Eat for Health © session, event, or from consuming food or other products recommended or served by Arnah Rudicil MHP. I waive my right to take legal action against Arnah Rudicil MHP, Eat For Health © and the host facility or platform. I affirm that Arnah Rudicil MHP and Eat For Health shall not be liable for any loss or injury due to health and nutrition information or ideas given.
I understand that Eat For Health may reach out to the phone number provided above (and email) to schedule my coaching appointment, and to clarify any questions concerning my health situation. I consent to be contacted for this purpose. I understand that Eat For Health will never disclose any of my above information, and commits to keep my medical information confidential. By signing my name here, I take 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 and consent of the client named above.
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Please Type YOUR OWN electronic signature here:
First Name
Last Name
In addition to your own signature above, if this form was completed on the behalf of someone else, please type THEIR name below:
First Name
Last Name
Date
MM
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You did it! Thank you for submitting your Client Intake Form.
Payment: Eat For Health requires payment in full prior
Cancellation Policy: If you need to cancel or reschedule, please do so at least 1 day prior to the appointment.
Location: Consultations can be conducted virtually or in-person (See meeting locations in New Paris, Ohio or Richmond, Indiana ).
5 Days preceding your coaching session: To make the most of your appointment, We ask that you please take photos of all foods and beverages that you consume for the 5 days preceding our coaching session, without making changes to your present diet. Please send the photos to Eat For Health © business phone: 937-683-0002.Just before your coaching session: come with a willingness to hear and learn. Please have paper and a pencil or pen, and arrive 15-20 minutes early for in-person appointments or 5 minutes early for virtual appointments.Please check your email or spam folder. EatForHealth@protonmail.com will email these important pre-session instructions, along with any additional information relevant to your coaching session.
