Nutrition Intake Form - Erica Breen Wellness

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Personal Information

Name(Required)

First Last

Email(Required)

Birthday

MM slash DD slash YYYY

City / Country

Emergency Contact

Name

Relationship

Phone

Health Overview

Health concerns (one per line)

Current symptoms

Diagnoses (if any)

Medications

Supplements currently taking

Lifestyle

Energy levels throughout the day

Sleep quality and patterns

Digestion (bloating, regularity, sensitivities, etc.)

Stress patterns and nervous system state

Nutrition Overview

Describe a typical day of eating

Any dietary preferences, restrictions, or sensitivities

What are you hoping to shift, rebuild, or better understand in your health right now?

What has or hasn’t worked for you in the past when it comes to nutrition or wellness?

Is there anything you feel hasn’t been heard, understood, or addressed about your health before?

Health

I confirm that:(Required)

I understand this is not medical or dietetic care

I will consult a licensed healthcare provider when appropriate

I will inform Erica Breen Wellness of any changes to my health status

Nutrition & Wellness Disclaimer

I understand that all nutrition and wellness guidance provided is educational and supportive in nature and does not constitute medical advice.

I acknowledge that:(Required)

I am responsible for my health decisions

I am responsible for seeking medical care when needed

Results vary and are not guaranteed

Supplement Responsibility

I understand that any supplement recommendations are optional.

I accept full responsibility for:(Required)

Determining their suitability

Proper usage and dosage

Any effects or outcomes

Privacy & Communication Acknowledgment

(Required)

I understand that communication may occur via email or virtual platforms, which are not fully secure.

I acknowledge that these services are not subject to medical confidentiality laws, including the Health Insurance Portability and Accountability Act (HIPAA), and I accept any associated risks.

I agree to use discretion when sharing sensitive personal or medical information.

Release of Liability

I knowingly and voluntarily release and hold harmless Erica Breen Wellness from any liability related to decisions I make regarding nutrition, supplements, or lifestyle changes, including those arising from negligence.(Required)

I agree

Indemnification

I agree to indemnify and hold harmless Erica Breen Wellness from any claims, damages, or expenses resulting from my participation.(Required)

I agree

No Guarantee of Results

I understand that outcomes vary based on individual circumstances, history, and participation, and no specific results are guaranteed.(Required)

I agree

Policies

• Sessions begin and end at scheduled times
• Late arrivals do not extend session time
• 24-hour cancellation required. Email ericabreenwellness@gmail.com or cancel in Google Meet invitation.
• Late cancellations or no-shows = full charge
• Payment due 24 hours in advance or session will be canceled
• All packages and sessions expire 6 months from purchase
• No refunds will be given

(Required)

I have read and agree to the Policies

Consent

(Required)

I have read, understood, and agree to the above information, policies, disclaimers, and liability terms. I acknowledge that I am responsible for my decisions and participation.

Your Signature(Required)

Date

MM slash DD slash YYYY