Client Intake FormPlease be as detailed as possible with the questions below and attach posing/full body pictures in suit or equivalent withresponses. (men do posing trunks or boxers) General Information QuestionnaireWhich coach are you applying to work with?(Required)Matt CusanoThomas SchneppIsa RodriguezKara FrachioniBella JonesNo PreferenceWhat type of coaching are you applying for?(Required)Functional Health CoachingContest Prep Coaching60 min consultationsLifestyle CoachingFull Name(Required) Age(Required)Gender(Required)Select GenderMaleFemaleGender(Required)MaleFemaleEmail(Required) Phone(Required)Current weight(Required) Height(Required) Years of intense training experience?(Required) Do you own and use a smart watch that tracks total daily calories and activity? (Apple watch, fitbit, galaxy)(Required)Any food allergies? Foods to avoid? ( This includes negative reactions to gluten, dairy, sugar, alcohol)(Required)Any current injuries?(Required)Any history of surgeries or major procedures?(Required)Rough idea of current diet/macros?(Required)How many meals do you prefer to eat?(Required)Current training schedule and rep schemes?(Required)What time of day do you normally train?(Required)Current cardio regiment (if any) ?(Required)Full History (if any) with advanced supplements? (dosages and timeline for use)(Required)What goals would you like to accomplish while working together? (Short term and long term)(Required)Please upload recent photos of your physique - front, side, and back Drop files here or Select files Max. file size: 5 MB, Max. files: 3. General Information Health QuestionnaireCategory 1 - Have you been diagnosed with, or experienced, any of the following? (Please tick appropriate answers) Anemia Anorexia Anxiety Depression Chronic Fatigue Diabetes Type 1 Diabetes Type 2 Endometriosis Polycystic Ovary Syndrome Gall Bladder Removal Graves Disease Hashimotos IBS IBD Stomach Ulcers Category 2 – Upper Gastrointestinal System - Do you experience any of the following? (Please tick appropriate answers) Belching after eating Bloating in the stomach region Heartburn or Acid Reflux Feel heaviness in the stomach after consuming meat Feel better skipping meals Fragile fingernails Brittle hair Hair loss Diarrhea after eating Undigested food in stool Frequent use of PPI’s or antacids Bad Breath Frequent Hiccups Frequent Hiccups Rosacea Have you been tested for H Pylori? If yes, was the result positive or negative?(Required)PositiveNegativeCategory 3 – Liver and Gallbladder - Do you experience, or have you experienced, any of the following? (Please tick appropriate answers) Pain between the shoulder blades Stomach upset by fatty foods Loose stools or oily substance in water Motion sickness Easily hungover when consuming alcohol Chronic fatigue or lethargy General Itchiness/Itchy Palms Feel sluggish after consuming fats Feel full for extended period after consuming fats Category 4 – Small Intestine / Microbiome - Do you experience, or have you experienced, any of the following? (Please tick appropriate answers) Bloating around the belly button region after eating Food Allergies / Sensitivities Hay fever, seasonal rashes or consistent sinus congestion Diarrhea/Loose stools Constipation Food Poisoning or travelers’ bug (even if once) History of UTI’s Dry eyes or mouth Nerve Pain Pins and needles or sleeping limbs Brittle hair Brittle fingernails Poor facial skin tone (e.g. looking washed out) Joint pain / Neck stiffness / Knee pain / Finger pain Tooth or mouth sensitivity Category 5 – Large Intestine / Acetaldehyde - Do you experience, or have you experienced, any of the following? (Please tick appropriate answers) White coating on your tongue Bloating below belly button Itchy Inner Ears Anus or Vaginal itching History of fungal or yeast infections Jock itch, dermatitis or, fungal rashes Excessively bad smelling gas Frequently pass gas Born via C section Stomach cramps Itchy scalp / dandruff Low motivation Overly sensitive to alcohol Blood in stool Sugar cravings Frequency of Bowel Movements?(Required)Less than once dailyOnce Daily2 or more per dayFrequency of Constipation?(Required)EverydayA few times per weekRarely everFrequency of Diarrhea?(Required)EverydayA few times per weekRarely everDo you currently take any prescription or over the counter medication? If yes, what are you taking? (e.g. Birth Control, NSAIDs etc)(Required)When was your last blood work? (If within 6 months, please upload results. If no recent panels have been done, we will go over what to get done together)(Required)Upload blood work results If within 6 monthsAccepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.On a scale of 1-10, please rate your current sleep quality and how many hours nightly on average? How many times do you wake up through the night? Do you wake up energized in the morning?(Required)Please describe your lifestyle and level of stress day to day?(Required)Men’s Health Questionnaire Please score each question with the following correlating number to the answer that most accurately describes your current status: 1) None, 2) Mild, 3) Moderate, 4) Severe, 5) Extremely SevereDecline in your general well-being(Required)Chronic joint pain or muscular aches(Required)Excessive sweating(Required)Sleep problems(Required)Increased need for sleep, often feeling tired(Required)Irritability(Required)Nervousness(Required)Anxiety(Required)Physical exhaustion(Required)Decrease in muscular strength(Required)Depressive mood(Required)Feeling that you have passed your peak(Required)Feeling burn out, having hit rock bottom(Required)Decrease in beard growth(Required)Decrease in ability/frequency to perform sexually(Required)Decrease in number of morning erections(Required)Decrease in sexual desire or libido(Required)Any other symptoms worth noting(Required)Part 2) Under each category below, please mark as many as you feel relate to you either currently or previously.Category A: Please mark a check box next to each statement you feel you identify with: I feel tired in the morning, even after a full night’s sleep. I depend on caffeine (coffee, energy drinks, etc.) to get through my day. I want to take naps most days. My energy crashes in the afternoon. I crave salty or sweet food. I’m dizzy when I stand up too quickly I feel at the mercy of stress. I have difficulty falling asleep and/or staying asleep. My muscles feel weaker. I get sick often and/or have a difficult time getting over infections. I have low blood sugar issues (Fasted Blood Glucose < 70 mg/dl). Category B: Please mark a check box next to each statement you feel you identify with My life is crazy stressful. I feel overwhelmed by stress. I have extra weight around my midsection. I have difficulty falling or staying asleep. My body is tired at night, but my mind is going a mile a minute – I’m “wired andtired”. I get a second wind at night that keeps me from falling asleep. I wake between 2 and 4 AM and can’t go back to sleep. I feel easily distracted, especially while under stress. I get angry quickly or just feel on edge. I have high blood pressure or a fast heart rate. I have elevated blood sugar or diabetes I get shaky if I don’t eat often. I’m prone to injury and have difficulty healing. Category C: Please mark a check box next to each statement you feel you identify with I have brain fog or feel like my memory isn’t quite what it used to be. I’m losing hair (scalp, body, outer third of the eyebrows). I’m constipated often and need a stimulant (like caffeine) or an OTC laxative to get a bowel movement. I’m cold and/or have cold hands and feet. I have joint or muscle pain. I have dry skin. I am in a low mood or struggle with depression I’m tired no matter how much I sleep. I find it difficult to break a sweat. I have recurrent headaches I have high cholesterol. I have a hoarse voice most days. Women’s Health Questionnaire Under each category below, please mark as many as you feel relate to you either currently or previously.Category A: Please mark a check box next to each statement you feel you identify with I sometimes feel bloating or puffiness I often feel irritable or experience mood swings. I experience heavy, painful periods I have gained weight or have difficulty losing weight, especially around my hips, butt, and thighs. I have been told by my doctor that I have fibroids. I sometimes cry over “nothing”. I often get migraines or other headaches. I sometimes experience brain fog. Category B: Please mark a check box next to each statement you feel you identify with: I’m emotionally fragile and/or I feel nostalgic about the past. I have difficulty with memory. My periods are shorter than 3 days. I struggle with depression, anxiety, lethargy. I experience night sweats and/or hot flashes. I’ve had trouble with recurrent bladder infections I sometimes have problems with urinary leakage I have difficulty sleeping and wake up in the middle of the night. My breasts are smaller and/or beginning to droop. I have achy joints or am prone to joint injuries. My sun-damaged skin is more noticeable I am noticing more fine lines and wrinkles. I have dry or thinning skin. I have no interest in sex. I have vaginal dryness or pain with intercourse. Category C: Please mark a check box next to each statement you feel you identify with I experience PMS seven to ten days before my period. I get headaches or migraines around my period. I feel anxious often. I have painful, heavy, or difficult periods. My breasts are painful or swollen before my period. I feel agitated, irritable, or weepy before my period. I have had a miscarriage in the first trimester. I experience restless legs, especially at night. I have had difficulty getting pregnant (after trying for six or more months) Category D: Please mark a check box next to each statement you feel you identify with: I have abnormal hair growth on my face, chest, and/or abdomen. I have acne. I have oily skin and/or hair. I have areas of darker skin (e.g., armpits, upper inner thighs near groin) I’ve noticed thinning hair on my head. I have skin tags. I struggle with depression and/or anxiety. I have been medically diagnosed by my PCP or OB/GYN with PCOS. I have had difficulty getting pregnant (after trying for six or more months). Category E: Please mark a check box next to each statement you feel you identify with I have a low libido or diminished sex drive. I struggle with depression, have mood swings, or cry easily. I have no motivation. I am tired or fatigued throughout the day or have been diagnosed with chronic fatigue syndrome. I’m unable to gain muscle, and I’m losing muscle mass. I have a decrease in bone density or have been diagnosed with osteopenia or osteoporosis. I have urinary incontinence. I have a loss of sexual fantasies. Category F: Please mark a check box next to each statement you feel you identify with I feel tired in the morning, even after a full night’s sleep. I depend on caffeine (coffee, energy drinks, etc.) to get through my day. I want to take naps most days. My energy crashes in the afternoon. I crave salty or sweet food. I’m dizzy when I stand up too quickly I feel at the mercy of stress. I have difficulty falling asleep and/or staying asleep. My muscles feel weaker. I get sick often and/or have a difficult time getting over infections. I have low blood sugar issues (Fasted Blood Glucose < 70 mg/dl). Category G: Please mark a check box next to each statement you feel you identify with My life is crazy stressful. I feel overwhelmed by stress. I have extra weight around my midsection. I have difficulty falling or staying asleep. My body is tired at night, but my mind is going a mile a minute – I’m “wired and tired”. I get a second wind at night that keeps me from falling asleep. I wake between 2 and 4 AM and can’t go back to sleep. I feel easily distracted, especially while under stress. I get angry quickly or just feel on edge. I have high blood pressure or a fast heart rate. I have elevated blood sugar or diabetes I get shaky if I don’t eat often. I’m prone to injury and have difficulty healing. Category H: Please mark a check box next to each statement you feel you identify with I have brain fog or feel like my memory isn’t quite what it used to be. I’m losing hair (scalp, body, outer third of the eyebrows). My hair is dry and tangles easily. I’m constipated often and need a stimulant (like caffeine) or an OTC laxative to get a bowel movement. I’m cold and/or have cold hands and feet My periods are sporadic or occur more than thirty-five days apart. I have joint or muscle pain. I have dry skin. I have had difficulty getting pregnant (after trying for six or more months) or have had a first trimester miscarriage. I am in a low mood or struggle with depression I’m tired no matter how much I sleep. I find it difficult to break a sweat. I have recurrent headaches I have high cholesterol. I have a hoarse voice most days. WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT 1. TBT and its agents are not medical doctors. Any advice provided is not intended to diagnose, treat, cure, or prevent any health problem - nor is it intended to replace the advice of a physician. Always consult your physician or qualified health professional on any matters regarding your health. I understand that supplement recommendations are made for entertainment purposes only and local laws should always be consulted before purchasing any supplements. 2. I am fully aware of the risks and hazards connected with the activities of physique development, bodybuilding, contest preparation and supplementation, and I am aware that such activities include the risk of injury and even death, and I hereby elect to voluntarily participate in said activities. I understand that TBT does not require me to participate in this activity. I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, including death, that may be sustained by me, as a result of being engaged in such activities, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise, to the fullest extent allowed by law. 3. I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE TBT, its officers, agents, or employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, while participating in such activities, REGARDLESS OF WHETHER SUCH LOSS IS CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise and regardless of whether such liability arises in tort, contract, strict liability, or otherwise, to the fullest extent allowed by law. 4. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage, or costs, including court costs and attorneys' fees that RELEASEES may incur due to my participation in said activities, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise, to the fullest extent allowed by law. 5. It is my express intent that this Waiver and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of North Carolina and that any mediation, suit, or other proceeding must be filed or entered into only in North Carolina and the federal or state courts of North Carolina. 6. I understand that all sales packages and/or payments for service are final and NON-REFUNDABLE. 7. I understand that all clients are subject to a 30 day cancellation policy. Notification must be given 30 days in advance of cancellation of services. Clients may put a pause on their coaching for up to 60 days. Upon completion of the 60 day freeze, if the client wishes to cancel coaching services, they will pay one final month of service as their 30 day notice. 8. I am aware that all information exchanged is property of TBT and is not to be shared or copied. IN SIGNING THIS AGREEMENT, I ACKNOWLEDGE AND REPRESENT THAT I have read it fully, understand it and sign it voluntarily as my own free act and deed IN WITNESS WHEREOF, I have signed this Waiver and Agreement under seal on thisDate(Required) MM slash DD slash YYYY CLIENT NAME(Required) Signature(Required)
