New Client Information & Agreement

RELEASE OF LIABILITY AND PRIVACY POLICY: I hereby agree to expressly assume and accept any and all risks of injury or death that I may suffer, and hereby irrevocably release SHAPE Health and Wellness Centre Inc., its agents, officers and employees from any liability with respect to these risks while participating in a health and wellness program. Informed Use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for persons who undertake physical activity. If in doubt after completing this questionnaire, please consult your doctor prior to physical activity. I accept these policies as they relate to nutritional counseling services with SHAPE Health and Wellness Centre Inc. I also agree to SHAPE collecting, using and disclosing personal information about me as set out in SHAPE’s Privacy Policy. Please telephone SHAPE 416-929-8444 (Eastern) to provide your CREDIT CARD INFORMATION. We will answer any questions or concerns and you may then complete the form below and Submit to SHAPE. You will then proceed to the INITIAL NUTRITION ASSESSMENT form ... I Agree Date: (mm/dd/yy) = Required Gender: male female 1. Name: 2. Address: 3. City: 4. Prov./State 5. Country: 6. Postal/Zip Code: 7. Home Phone: 8. Cell Phone: 9. Business Phone: 10. Occupation: 11. Employer: 12. Date of Birth (mm/dd/yy): 13. Personal Email Address: 14. How you heard about SHAPE: 15. Name of your family doctor: 16. Doctor's phone number: 17. Your last physical (mm/dd/yy): 18. Briefly describe your medical history: 19. Please list any medications, vitamins or supplements you take: 20. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? Yes No 21. Do you feel pain in your chest when you do physical activity? Yes No 22. In the past month, have you had chest pain when you were not doing physical activity? Yes No 23. Do you lose balance because of dizziness or do you ever lose consciousness? Yes No 24. Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No 25. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure and / or heart condition? Yes No 26. Have you ever tested HIV positive? Yes No 27. Have you ever been diagnosed with cancer? Yes No

 

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