Metabolic Balance Paperwork

PERSONAL PROFILE

Name: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Email: *

Home Phone Number:

Cell Phone Number: *

Date of birth: *

Profession:

Height: *

Weight: *

Goal Weight: *

Please click HERE to download a guide on how to measure your circumferences correctly.

Navel Circumference: *

Hips Circumference: *

Upper Thigh Circumference: *

Are you a body builder? *

No
Yes

If yes, what is your bicep circumference?

How did you find out about Metabolic Balance®? Recommended by:

Other:

Declaration of Consent and Privacy Practice

I concur that my coach provides the following information to Metabolic Balance GmbH& Co.KG: *

Personal data
Information on health and medical history
Blood values
Details about my eating habits (also food allergies)

The aforementioned data is sent to Metabolic Balance GmbH & Co. KG to allow said company to create a nutrition plan as part of the participation of the Metabolic Balance® Program. After the creation of the nutrition plan, Metabolic Balance GmbH & Co. KG will transmit the plan to your personal coach. Thereby your personal coach has access to the above data and nutrition plan to provide comprehensive advice under the Metabolic Balance® nutrition concept to you. Your coach and Metabolic Balance® will use your data solely for the above purposes and will not pass it on to third parties. We need your personal details and health data to be able to fulfill our contractual obligation to create a personalized nutrition plan and provide comprehensive coaching sessions to you. Under Art. 15 of the General Data Protection Regulation (GDPR), you are entitled to ask the contractual parties at any time for full details of the personal data collected about your health and person. In addition, under Art. 17 of the GDPR you are entitled at any time to demand the correction, deletion or suspension of individual items of personal data. Moreover, you are entitled, at any time and without stating a reason, to exercise your right of refusal and to modify your given consent for future purposes, or revoke it entirely. You can send your revocation either by mail or email to your contractual partner (your personal coach, see above). In cases of data privacy violations, the data subject is entitled to lodge a complaint with the competent supervisory authority. The competent supervisory authority for data privacy issues is the data privacy representative of the German Federal State in which our company has its registered headquarters.

I concur that my coach provides the following information to Metabolic Balance GmbH& Co.KG: *

I agree in the aforementioned usage of my personal data.

Information on health and medical history: *

Other:

Pregnant? *

Yes
No

Allergies? *

Yes
No

If yes, list allergies:

Medications? *

Yes
No

To treat:

Other (e.g. Contraceptive/Hormone replacement)

Information on food consumption / Eating habits as well as food allergies

I eat everything: Meat, Poultry, Fish, Cheese, Seafood, Soy

Yes
No

I seldom eat (choose each that applies):

I refuse to eat (choose each that applies):

With Metabolic Balance® I anticipate:

Weight loss
Balancing of the metabolism

How do you evaluate your state of health on a scale of 0 to 10? (0 = very bad to 10 = excellent) *

Food Preferences:

Would you be willing to eat mushrooms as your protein for some meals if this would be beneficial for your body? *

Yes
No

Are you willing to eat eggs? *

Yes
No

Please indicate any other dietary restrictions:

Please fast 12 hours before blood drawing - only pure water is allowed, do not eat or drink anything else!

Initial Questionnaire

What are your goals in beginning Metabolic Balance? *

Weight loss
Weight gain

If so, how many pounds would you like to either lose or gain?

Other goals:

Please take a moment to review these important details regarding this program. Once you have read and understood each point, please check the box to initial that you agree to do these requirements.

#1: *

This program requires strict adherence to all rules and guidelines for 2 days of preparation and then at least 2 weeks after that. You will need to carefully select a start date that allows you to remain strict during this initial time period.

#2: *

You must consume exactly three meals daily.

#3: *

You must comply with the plan (quantities, rules, etc.) to see results. Lack of compliance may result in you not reaching your goals.

#4: *

You will need to consume one apple a day (if you are sensitive to apples, please let your coach know and they will guide you on how to reverse this sensitivity.)

#5: *

You must be ready to make necessary lifestyle changes for the sake of your health and longevity!

#6: *

Sports or exercise should be limited during the Strict Phase.

#7: *

Your recommended amount of water must be drunk daily.

#8: *

Choose a convenient time to start the program so that you set yourself up to succeed!

#9: *

In order to participate, you must be willing to eat fruits and vegetables, a variety of foods (including protein sources), and you must not be vegan.

#10: *

Diabetics may participate, since food intake consists of low glycemic load; these participants will also consume 3 meals daily.

#11: *

You may not participate if you are pregnant, breast-feeding, undergoing strong neuroleptic treatment, or suffering from renal insufficiency.

Please review the following information about your lab work and check the box to initial that you have read and understand. Your folder contains additional instructions from Ulta Labs for your review.

#1: *

Your order will be sent to the email address you provided above.

#2: *

Sampling of blood should be performed after fasting for 12 hours (overnight is recommended) with only water permitted during those hours.

Please indicate any present Illnesses/Allergies:

Please click HERE to read our Metabolic Balance Consents and Disclaimers and our Agreement and Release of Liability form. Then, sign below. By signing, you are acknowledging that you have read and accept the terms and conditions.

Client Signature: *

Clear Signature

Today's Date: *

Metabolic Balance Paperwork

New Client Appointment Checklist

These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

Please understand the importance of keeping your appointments. We do have a 48 hour new client/24 hour regular client appointment cancellation policy that is strictly enforced.

New Client Form

PERSONAL PROFILE

Declaration of Consent and Privacy Practice

Information on food consumption / Eating habits as well as food allergies

Food Preferences:

Initial Questionnaire

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