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    Please be as thorough as possible when completing this form. It will require a few minutes to complete, so be sure to set aside about 20 minutes so that you're not rushed when answering the questions. This information is essential in helping us to formulate the right plan for your circumstances. If you have any questions, please don't hesitate to contact us at support@fxpathlete.com

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    Step 1/9

    General Information

    Please let us know your name.

    Please let us know your name.

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    Please let us know your email address.

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    Step 2/9

    Guardian & Emergency

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    ^ Full name of the parent/guardian completing this form.

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    Step 3/9

    General Athlete Profile

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    ^ Current height in inches

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    Step 4/9

    Training Profile and History

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    (use format above i.e.; "8:00am/1.5hrs/Strength Training"... use separate lines for additional training sessions on that day)

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    (use format above i.e.; "8:00am/1.5hrs/Strength Training"... use separate lines for additional training sessions on that day)

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    (use format above i.e.; "8:00am/1.5hrs/Strength Training"... use separate lines for additional training sessions on that day)

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    (use format above i.e.; "8:00am/1.5hrs/Strength Training"... use separate lines for additional training sessions on that day)

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    (use format above i.e.; "8:00am/1.5hrs/Strength Training"... use separate lines for additional training sessions on that day)

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    (use format above i.e.; "8:00am/1.5hrs/Strength Training"... use separate lines for additional training sessions on that day)

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    (use format above i.e.; "8:00am/1.5hrs/Strength Training"... use separate lines for additional training sessions on that day)

    Step 5/9

    Nutrition Profile and History

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    Check all drinks that you have regularly

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    (i.e.; "Green Tea/2 Cups")

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    (i.e.; "Monster/16 Ounces")

    Step 6/9

    Nutrition Profile and History II

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    Step 7/9

    Nutrition Profile and History III

    How many times per week do you eat the following

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    (MO/DY/YY)

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    Health History

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    (check all that apply above, or check "None")

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    Step 9/9

    Informed Consent Form and Terms for Nutritional Counseling

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    I hereby give consent to FXP Athlete and Simona Hradil, RD to provide Nutrition Counseling to myself, or the client for which I am legally responsible. The consult will provide information and guidance about health factors within my own control: my diet, nutrition, and lifestyle.

    I understand that Simona Hradil is a Registered Dietitian/Nutritionist and not a medical physician, and does not dispense medical advice, nor will she diagnose or treat any medical condition, but will provide nutritional support and nutrition education for an already diagnosed condition. She provides education to enhance my knowledge of health through the use of whole foods, dietary supplements, and emotional awareness. While nutritional and botanical support can be an important compliment to my medical care, I understand nutrition counseling is not a substitute for the diagnosis, treatment, or care of disease by a medical provider.

    Methods of nutritional evaluation or testing made available to me are not intended to diagnose disease. Rather, these assessment tests are intended as a guide to developing an appropriate health-supportive program for me, and to monitor my progress in achieving my goals.

    Medical records and personal information and history divulged in sessions to FXP Athlete [Simona Hradil, RD] will be kept confidential, unless I consent to sharing my medical information. I understand that Simona Hradil, RD will keep therapy notes as a record of our work together. These notes document the topics that we talk about, interventions used, and treatment plan or any other considerations that may be helpful to your work with me. Records will be stored in a secure location.

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    I agree to hold FXP Athlete [Simona Hradil, RD] harmless for claims or damages in connection with our work together. This is a contract between myself and Simona Hradil, RD and I understand that it is also a release of potential liability.

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    I acknowledge that I have read and understand the HIPAA privacy agreement found online at Click Here to sign

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    I acknowledge that nutrition counseling for sports specific weight categories is an individual process with many variables, and therefore FXP Athlete can make no guarantees. FXP Athlete and Simona Hradil, RD do not guarantee any athlete will make weight and are in no way responsible if an athlete fails to reach his or her desired weight category. I acknowledge that the information and guidance provided by FXP Athlete to me is a service based on methods proven in science and real world clients, however, this does not guarantee success in every individual, thus there are no refunds if said athlete fails to reach his or her weight category.

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    Payment is required at the time of service. Cash, check and major credit cards are accepted. Nutrition counseling services may be terminated at the discretion of Simona Hradil, RD if written notification is provided to a client 30 days in advance of final appointment. This will include a listing of referrals for continuity of care.

    I UNDERSTAND, HAVE READ AND UNDERSTAND THIS LIABILITY RELEASE AGREEMENT. I AFFIRM THAT I HAVE THE AUTHORITY TO ENTER INTO THIS AGREEMENT FOR MYSELF (OR IF PARENT/GUARDIAN- ON BEHALF OF THE MINOR PARTICIPANT). BY ENTERING MY NAME BELOW, I AM REPRESENTING AND I AGREE TO BE BOUND BY THE TERMS OF THIS AGREEMENT.
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