Please fill out the following information and click the SUBMIT FORM button at the bottom.

Date:
Name:
Address:
City:
State:
Country:
Zip:
Cell Phone:
Home Phone:
Work Phone:
Email:
Emergency #:

Personal Profile Information

Gender:  Height:  Weight:  Body Fat %:  Birth Date: 

Weekly Exercise Information

Explain what type of resistance exercises, cardiovascular or sports activities you perform during an average 7-day period.

Exercise/Activity Days/Week Duration

Lifestyle/Professional Activity

How would you rate the activity level of your profession, or what you do during the day (non-exercise related)?

Sedentary Moderately Active Active Very Active

What are your goals?

Weight Loss Maintain/Improve Eating Habits Fitness Competition
Figure Competition Gain Muscular Size Gain Strength
Sport-Specific: 
What is your goal weight? 

Which best describes you?

Sedentary Adult Exercising Adult Competitive Athlete Growing Teen Athlete
Adult Building Muscle Athlete Restricting Calories

Body Type

Which of the following statements best describes you?

I can eat practically anything I want and I don’t gain weight. I find it hard to gain weight.
I can lose or gain weight by adusting my activity level and eating habits.
I find it difficult to lose weight. I can gain weight easily and have to watch what I eat.

Health & Medical Conditions

Check off any health conditions listed below that apply to you and describe any other(s) not listed.

Heart Disease Anemia Hypoglycemia Liver Disease Kidney Disease
Diabetes Pancreatic Disease Lactation Hypertension
Other:
Please list all medications you are currently taking:
What time do you normally wake up? 
What time do you normally go to bed at night? 
If you smoke, how many per day? 
If you smoke, how many years have you smoked? 
If you drink alcoholic beverages, what and how many per day?
Are you allergic to any types or kinds of foods?
Have you ever been placed on any type of nutritional program in the past? 
If yes, by whom and what did it consist of? Please explain below:
What were your results?
Have you ever had your body fat tested? 
If yes, how was it tested and when?

Food Information

Please list below everything you eat in one 24 hour period. Be sure to include snacks and beverages, including water. Also, show approximate amounts.

Time:  Food/Beverage: 
Time: Food/Beverage:
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Time: Food/Beverage:
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Time: Food/Beverage:
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Make a list of your favorite foods:

Protein sources:
Fruits and vegetables:
Starches:
Healthy Fats:
Cravings:

Make a list of foods you DISKLIKE:

I AGREE TO ALLOW Carla Sanchez, CSCS, WEIGHT MANAGEMENT CONSULTANT, TO DESIGN A WEIGHT MANAGEMENT PROGRAM FOR ME TO ENHANCE MY HEALTH & FITNESS GOALS. I WILL FOLLOW THAT PROGRAM TO THE BEST OF MY ABILITY AND I WILL NOT HOLD Carla Sanchez, CSCS OR ANY ONE RELATED PERSONS OR PARTIES PERSONALLY LIABLE FOR ANY PROBLEMS, ILLNESSES OR INJURIES THAT MIGHT OCCUR DUE TO A SUDDEN CHANGE IN MY EATING HABITS. I UNDERSTAND THAT Carla Sanchez, CSCS IS NOT A REGISTERED OR LICENSED DIETITIAN, NOR A MEDICAL PRACTITIONER. THIS WEIGHT MANAGEMENT PROGRAM DOES NOT REPLACE THE EXPERT ADVICE OR MEDICAL TREATMENT OF MY OWN PRIVATE DOCTOR. I HAVE GIVEN Carla Sanchez, CSCS ALL NECESSARY INFORMATION ABOUT MYSELF TO PREVENT ANY POSSIBLE COMPLICATIONS.
I agree to these terms Date: 

Sellers (Consultant) and Purchasers (Client) Hold Harmless and Indemnification Agreement

I, the undersigned (“the Purchasers”) hereby warrants that I will indemnify and hold harmless Carla Sanchez of Performance Ready, LLC and Lifestyles Technologies, Inc., known hereafter as (“the Sellers”), and its officers, directors, agents and employees. This indemnification and hold harmless warranty extends to Sellers, individually and separately, and, the corporation’s successors, and subsidiaries, as against any and all claims, demands, actions, and causes of action, including personal injury, and all other liability whatsoever, including, but not limited to, costs, attorney’s fees and/or judgments which arise out of the use of the DietMaster Pro weight management program.

The undersigned, as Purchaser(s) further warrant the program is to be utilized within the State(s) of , and it will hold harmless and indemnify the Sellers corporation, its agents, directors, officers, employees and individuals named in paragraph one of this Hold Harmless and Indemnification Agreement, against any and all claims for liability and/or damages, arising from any and all violation(s) of Codes, Statutes, Licensing Procedures, Licensure Examinations and/or Registration Requirements, of such state(s), which govern the practice of dietetics and/or weight management and/or nutritional counseling and/or advise, whether known or unknown to the Purchaser(s) at the time of purchase and subsequent use with the public of the DietMaster Pro weight management software program(s). Such indemnification includes, but is not limited to costs, attorney’s fees, and damages, whether or not reduced to judgment and judgments which might arise from such claims, law suits, and/or administrative filings.

The indemnification includes all costs and attorney fees incurred by the Sellers in the investigation and defense of any claim enumerated in paragraphs preceding prior to a determination of an exact date of an occurrence and/or incident and/or violation upon which such alleged claims may be based.

It is further understood and agreed by the Purchaser(s), that the consideration for this Indemnification and Hold Harmless Agreement, benefiting the Seller, its agents, directors, officers, employees and the individuals named in the paragraphs preceding is the “weight management software content of the program.”

Signature of Purchaser(s), confirms that Purchaser(s) have agreed to be bound by the terms of the Indemnification and Hold Harmless Agreement and are contractually bound to indemnify the Sellers and its agents, directors, officers, employees and the individuals named in paragraphs preceding, and such obligation includes the responsibility to pay any and all costs and attorney’s fees which may be incurred by the Buyer in defending its agents, directors, officers, employees and individuals named in the paragraphs preceding.

I agree to these terms Date: 

GC_Formmail 1.2.1 by Giuseppe Calbi
©2008 Performance Ready