Form 1

Section 1: Client Information

Male Female

Note: For waist measurement, place tape measure in line with your belly button.

Section 2: Medical History

Yes No Yes No

Disclaimer: FoodChange make the following disclosures: The provision of Food Coaching, and the provision of holistic coaching, is intended as a guidance tool for assisting clients towards their own ultimate goals. Neither provision is in any way a replacement, or substitution for, professional medical or psychological assistance. Clients who have a medical or psychological disorder or illness must seek relevant professional medical or psychological advice. All information supplied by the client to the Coach/Counsellor is confidential and the client may request to view their own personal information, stored in the Coach/Counsellors records. Information will not be given to third parties in relation to the client or the clients personal details without the permission of the client, unless the Coach/Counsellor deems the client, or any other person associated with the client, to be in a serious or life threatening situation, in which case the Coach/Counsellor is duty bound to report the perceived danger to the appropriate authorities. Such incidences may include suicidal tendencies or physical, mental or emotional abuse being committed on or by the client.

I hereby acknowledge that I have been provided with the above information, have read such, and agree.