Precise Nutrition
Enrollment Form 1
Email address *
Name *
Your answer
Telephone number (with country code) *
Your answer
City & Country of Residence *
Your answer
Waiver and Release of Liability
In consideration of the risk of injury while participating in nutritional counseling (the "activity"), and as consideration for the right to participate in the activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the activity, and do hereby release and forever discharge Ashwairya Capital Management LLC located at Houston, TX their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned activity, including traveling to and from an event related to this activity.

I am voluntarily participating in the aforementioned activity and I am participating in the activity entirely at my own risk. I am aware of the risks associated with traveling to and from as well as participating in this activity, which may include, but are not limited to, physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and death. I understand that these injuries or outcomes may arise from my own or others' negligence, conditions related to travel, or the condition of the activity location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my participation in this activity, including travel to, from and during this activity.

I agree to indemnify and hold harmless against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If incurs any of these types of expenses, I agree to reimburse Ashwairya Capital Management LLC.

I acknowledge that Ashwairya Capital Management LLC and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Ashwairya Capital Management LLC.

I acknowledge that I have carefully read this "waiver and release" and fully understand that it is a release of liability. I expressly agree to release and discharge and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against for personal injury or property damage.

To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of Ashwairya Capital Management LLC, its agents, and employees.

In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Waiver release *
Required
Program Overview
Liability disclaimer:
• This is a strictly nutritional/lifestyle counseling service.
• This is not medical advice. Please consult your physician for any medical advise.

Blood Work
(Optional, for greater accuracy) At least every 3 months, test for the following:
• Complete cholesterol
• Fasting blood sugar
• Hemoglobin A1C

Equipment Needed
(Optional, for greater accuracy) Once the program begins, a list of recommended vendors will be provided for the following:
• Body weighing scale (~$40)
• Body fat monitor (~$40) or soft measuring tape (~$5)
• Food scale ($20)
• Blood pressure monitor ($50)
• Heart rate monitor ($100 - $300)
• Food journal app ($0)

Sample daily habits
• After waking up measure weight, body fat, blood pressure
• (Optional, for greater accuracy) Throughout the day, comply with nutritional and exercise plan and record food and drinks in the food journal app
• During workouts, wear heart rate monitor

Weekly expectations
Client’s preferred rate of change determines the pace of improvement in
• Weight, body fat
• Blood pressure, cholesterol, blood sugar
• Hair, nails, and skin, overall well being

Consultation Packages
• Diagnostics are conducted during initial on-boarding and are non refundable
• Consultation packages come with a two-week risk free trial. If unsatisfied within 2 weeks, 100% money would be refunded. All consultation packages expire 8 weeks from purchase date
• Optima Nutrition recommends food and exercises to be incorporated into lifestyle
• Optima Complete specifies the exact amount of food to be consumed and duration of exercises
Diagnostic package: Select one package *
Consultation package: Select one package *
Data: Macro-measurements
Date of Birth
MM
/
DD
/
YYYY
Age *
Your answer
Sex *
Height (inches)
Your answer
Height (cm)
Your answer
Weight (lbs)
Your answer
Weight (kg)
Your answer
Body fat (%)
Your answer
Pregnant *
Lactating *
Body type *
Fitness Goals *
Lifestyle (exclude workouts) *
Sedentary (v little physical work)
Extra heavy (v physically demanding work)
Data: Exercise
Exercise: Strength (Hours/week) *
Your answer
Exercise: Flexibility (Hours/Week) *
Your answer
Exercise: Cardio (Light, Less than 60% of max heart rate) *
Your answer
Exercise: Cardio (Moderate, 60 - 80% of max heart rate) *
Your answer
Exercise: Cardio (Heavy, more than 80% of max heart rate) *
Your answer
Data: Lifestyle choices
Current Habits: Cigarettes/cigars per week? *
Your answer
Current Habits: Alcohol per week? (oz) *
Your answer
Current Habits: Aerated drinks per week (oz) *
Your answer
Food diary
Generally what do you eat
Dietary preference *
Required
What do you generally eat for breakfast?
Your answer
What do you generally eat for lunch?
Your answer
What do you generally eat for dinner?
Your answer
What do you generally snack on?
Your answer
What do you generally like to drink?
Your answer
Daily routine
Just a few words - work, workout, eat breakfast / lunch / snack / dinner, socialize etc.
If you eat/drink, please briefly describe what you eat / drink.
What is your normal routine: 12 am - 3 am
Your answer
What is your normal routine: 3 am - 6 am
Your answer
What is your normal routine: 6 am - 9 am
Your answer
What is your normal routine: 9 am - 12 pm
Your answer
What is your normal routine: 12 pm - 3 pm
Your answer
What is your normal routine: 3 pm - 6 pm
Your answer
What is your normal routine: 6 pm - 9 pm
Your answer
What is your normal routine: 9 pm - 12 am
Your answer
Family medical history
Having a family history of certain conditions is likely to increase your risk
Do your grandparents have a history of cardiovascular disease - hypertension, cholesterol, or diabetes? Anything else?
Your answer
Do your parents have a history of cardiovascular disease - hypertension, cholesterol, or diabetes? Anything else?
Your answer
Do your siblings have a history of cardiovascular disease - hypertension, cholesterol, or diabetes? Anything else?
Your answer
Allergies
Our recommendations avoid your food allergies
List any food allergies *
Your answer
Desired treatment pace
While positive effects are seen within a few weeks, getting off medication takes 3 months. 6 months is the recommended treatment duration.
How motivated are you? *
Prepared to make no changes to current food choices and exercise routine
Prepared to make any sacrifice to current food and exercise routine
Blood Work
If you do not have blood work (blood pressure, cholesterol, blood sugar), just check boxes on current medical problem. If you prefer to get tested, some or all of the tests can be conducted after the program begins.
Your goals *
Required
Blood Work (Optional)
• Before the program begins, clients are requested to have the current values of their blood work. Any blood work within the prior 90 days would be considered current.
• If clients do not have blood work, the treatment will be a bit more generic

• If blood work was conducted more than 90 days prior, these results can be used to begin the program. All the same, the client would be recommended to get current blood work numbers at the earliest. Thereafter, the current numbers would be incorporated in recommendations going forward.

Macro measurements required
• Age
• Sex
• Height (feet, inches)
• Weight (lbs)
• Body type
• Special condition: Athlete, pregnant, lactating

Clinical measurements required
• Blood pressure measurement
- Systolic (mm Hg)
- Diastolic (mm Hg)
- Resting pulse (bpm)
Normally, these measurements are conducted complimentary upon check in into any healthcare facility. This measurement is non-invasive and only takes a few minutes to be completed.

• Blood work: Lipid profile (“Complete cholesterol”)
- Total cholesterol
- HDL cholesterol
- LDL cholesterol
- Triglycerides
Normally, these measurements are conducted as part of the annual medical check up. This test may require 12-hour fasting (no food or drinks) before being conducted. This test requires a small blood draw from a vein in the left/right arm and takes a few minutes to be completed. This is a very common test and any clinical laboratory should be able to conduct it.

• Blood work: Blood sugar
- Total blood sugar (fasting)
- Hemoglobin A1C (“A1C test”)
While total blood sugar is normally conducted as part of an annual check up, Hemoglobin A1C will have to be specifically requested. These tests also require a 12-hour fasting (no food or drinks) before being conducted. This test requires a small blood draw from a vein in the left/right arm and takes a few minutes to be completed. This is a very common test and any clinical laboratory should be able to conduct it.

• These blood tests are the most commonly requested tests and are readily available through a physician's order, walk in test at a pharmacy, or grocery store clinic. Walmart offers these test packages for $29.

Data: Blood pressure (Optional)
If tests were conducted in the last 60 days, they are considered valid. Otherwise, a new set of tests would recommended.
Date: Blood Pressure measurement
MM
/
DD
/
YYYY
Current Blood Pressure: Systolic (mm Hg)
Your answer
Current Blood Pressure: Diastolic (mm Hg)
Your answer
Current Resting Heart Rate: Pulse (bpm)
Your answer
Data: Cholesterol (Optional)
If tests were conducted in the last 60 days, they are considered valid. Otherwise, a new set of tests would recommended.
Date: Cholesterol test date
MM
/
DD
/
YYYY
Current Cholesterol: Total (mg/dL)
Your answer
Current Cholesterol: HDL (mg/dL)
Your answer
Current Cholesterol: LDL (mg/dL)
Your answer
Current Cholesterol: Triglycerides (mg/dL)
Your answer
Data: Blood Sugar (Optional)
If tests were conducted in the last 60 days, they are considered valid. Otherwise, a new set of tests would recommended.
Date: Blood sugar test
MM
/
DD
/
YYYY
Current Blood Sugar: Fasting blood glucose (mg/dL)
Your answer
Current Blood Sugar: Hemoglobin A1C (%)
Your answer
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