PERSONAL INFORMATION

Name:

Address:

City:

State:

Zip:

Home Phone:

     Work Phone:     Cell Phone:

E-mail:

Date of birth (mm/dd/yy)

Male:   Female:

Relationship Status:

Select One Married Single Committed Relationship Divorced Separated

If you have children, please list their names and ages:

Occupation:

GENERAL HEALTH HISTORY

Describe your general health:

Select One Excellent Good Fair Poor Very Poor

Height:

                   Frame size: Select One Small Medium Large

Body weight:

Current body weight:

Goal body weight:

One year ago:

Two years ago:

Five years ago:

Ten years ago:

GOALS

List your goals in the below areas, and select the priority level (1-5), where Priority 1 is the highest level of priority. Add details where possible. You can have more than one goal with the same priority:

Fitness Goals - Priority: None 1 2 3 4 5

Nutrition Goals - Priority: None 1 2 3 4 5

Weight Goals - Priority: None 1 2 3 4 5

Stress Management Goals - Priority: None 1 2 3 4 5

Health Goals - Priority: None 1 2 3 4 5

Other Goals - Priority: None 1 2 3 4 5

Check the goals you would like to work towards:

Weight-management    #of pounds to loose

Increase energy/productivity

Improve appearance

Feel/look younger

Improve muscle tone

Improve muscle mass

Decrease stress

Better sleep

Improve self esteem

Decrease depression

Decrease alcohol consumption

Decrease tobacco consumption

Improvement of one or more medical conditions

What else do we need to know to help you reach your goals?

What is the first area you would like to work on with your coach?

How would you describe your ideal personal coach?

What are your scheduling preferences?
(days and times you are most available)

What days and times are you not available?

What is your preferred coaching style?

Is there anything else that we should know?

AGREEMENT OF RELEASE OF LIABILITY

In consideration of my being allowed to receive wellness coaching services from a Licensed Wellcoach, and, in that process, to be coached in fitness, nutrition, weight management, stress management, and/or health risk management, I do hereby waive, release, and forever discharge Wellcoaches Corporation and its officers, agents, independent contractors, employees, representatives, executors, and all others from any and all responsibility or liability for injuries or damages resulting from my participation in any activities or my use of fitness equipment or any other equipment or machinery arising out of my participation in any activities under such coaching. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of wellness coaching.

I understand that as a part of the wellness coaching I may be coached to, or it may be suggested that I, participate in fitness activities, e.g., exercise, aerobic training, strength training, flexibility training, etc., that could be potentially hazardous. I also understand that such activities involve risks of injury and even death, and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death.

I further understand that my Licensed Wellcoach or my Licensed Corporate Wellcoach, as applicable, is an independent contractor and not an agent of Wellcoaches Corporation.

I do hereby further acknowledge that I have either had a physical examination and have been given a physician's permission to participate or that I have decided to participate in activity and or use of equipment and machinery without the approval of my physician and do hereby assume all responsibility and risks of injury or death from such participation and activities.

  I accept the above agreement of release of liability.