New Client Assessment
Please fill out the form below.

This Client Assessment Form is a way for me to get to know you, your lifestyle and your specific goals as a client.
Please answer all questions as accurately as you can.

MEDICAL NOTE:

Before beginning your program, please visit your physician for standard blood work and a check-up in order to ensure that you have a clean bill of health.

This program is not intended to replace your physician’s recommendations and/or advice regarding decisions related to your health.
1. Full Name *
2. Email Address *
3. Gender *
4. Age *
5. Height *
6. Weight *
7. Average Hours of Sleep *
8. Quality of Sleep *
Poor
Perfect
9. Rate Your Daily Stress Level *
No Stress
High Stress
10. What is your primary goal for this program?
Clear selection
11. What do you want to achieve in the next 4-6 weeks? *
12. Are you currently exercising? *
13. How many days per week do you currently exercise?
14. How long do you usually exercise?
15.What types of exercise do you currently enjoy?
16. Are you familiar with weight training?
Clear selection
17. What type of equipment do you have access to? *
18. What exercise programs have you tried in the past? *
19. Please list any current injuries or health problems below: *
20. Please list any medications you are taking below: *
21. How active are you during the day? *
22. What does your average week look like? *
Errands, going out, staying in bed, etc.
23. What does your average weekend look like?
24. Do you smoke? What, and how often? *
25. Do you drink alcohol? How often? *
26. How many meals do you eat each day? *
27. How often do you eat out?
Clear selection
28. Are you currently following a specific diet or nutrition plan? If so, describe it below.
29. What does an average day look like, food wise?
30. Have you ever had an eating disorder or thought you may have an eating disorder?
Please share below in as much or little detail as you feel comfortable sharing
31. Do you have any food allergies, if so, what are they?
32. Do you enjoy eating breakfast? *
33. Have you tried intermittent fasting? If so, what were your experiences? *
34. Please submit the following measurements *
Unflexed: 1) Waist at belly button, 2) Waist 2 inches above bb, 3) Waist 2 inches below bb, 4) Upper Arm midpoint of elbow and shoulder 5) Upper Leg midpoint of knee and hip
35. Any other details you would like to add?
DISCLAIMER *
The information in this program, "Weight Loss on the Wild Side," is provided for educational purposes and is not intended to treat, diagnose or prevent any disease. The information on this website, www.breannekallonen.com, & in the private Facebook group is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as sharing of knowledge and information from the research and experience of Breanne Kallonen and her community. Breanne Kallonen, encourages you to make your own health care decisions based upon your research and in partnership with a qualified heath care professional. Do you understand?
LIABILITY RELEASE : INITIAL BELOW *
*By entering your initials below, you (The Client) herby releases, indemnifies, and holds harmless, the Service Provider (Breanne Kallonen) from any and all manner of actions, causes of action, suits, proceeding, debts, dues, contracts, judgments, damages, claims and demands whatsoever in law or equity stemming from the agreement between the below mentioned parties. The Client expressly agrees that this release, waiver, and indemnity clause is intended to be as broad and inclusive, and if any portion thereof is held invalid, it is agreed the balance shall, notwithstanding, continue in full legal force and effect. The Client has carefully read the foregoing release and indemnification clause and understand the contents thereof. The Client acknowledges and is made fully aware that Breanne Kallonen is not a medical doctor and that the Service Provider is only providing recommendations to The Client in question. The Client acknowledges before beginning, implementing, or using any and all of recommendations provided, that client should consult a medical doctor.
NDA & STUFF: INITIAL BELOW *
*I shall hold and maintain the Confidential Information passed on to me during my time as a Client of Breanne Kallonen in strictest confidence, understanding it is for my sole and exclusive benefit. I shall carefully restrict access to Confidential Information (including all Electronic Communication, such as my individual coaching program) to third parties as is reasonably required. I shall not, without prior written approval of Breanne Kallonen, publish, copy, or otherwise disclose to others, or permit use by others for their benefit or to the detriment of Breanne Kallonen, any Confidential Information.
COMMITMENT AND TERMS: INITIAL BELOW *
I understand that this program requires my commitment as the client. By initialing below, I promise to do my very best and give my all to achieving my fitness goals for the full duration of the program.
Thanks!
My mission is to help you change your body, create a sustainable healthy lifestyle, and feel great about accomplishing your goals. I believe you can feel phenomenal in your skin, empowered, and full of energy! I can't wait for you to get started and for you to discover the BEST version of you.

xoxo

Breanne
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