PersonalTrainingandNutritionProfile

Name Birth Date Male Female Current Weight

Address

Phone
Home Cell Work

Emergency Contact

Name Phone Email

Occupation & Description

Time(s) and frequency available for training

Work schedule

Married? Yes No

Any children? Yes No If so, how many and ages

Most notable challenges (personal and circumstantial) in sticking with a fitness/nutrition plan

Physician

Name Number Address

Current diseases/medical conditions:

Current medication:

Any allergies:

Any physical/anatomical restrictions or chronic/recurring pain? Please Describe.

Past surgeries? If so, what and when?

Any diseases/serious health conditions prominent in family?

If you were allowed only one "bad" meal, what would it consist of?

Before making payment, this form MUST be filled out completely and
received by Nicki before an invoice will be drafted and subsequently, a
money request will be sent.

By submitting this form you are aware of payment protocol, rates, late
fees and training and nutrition policies described on this website.

You are aware that Nicki will contact your health care provider (if
applicable) prior to beginning any training or nutrition program to
ensure a safe and healthy environment and program.

You understand the risk associated with weight training and will follow
instruction while under the direction of Nicki to avoid injury.

You understand that communication, trust and compliance are essential
to creating an optimal team and without these, attaining your goals will
be difficult.

You understand that while I will put together the most sound and
appropriate program(s) possible, it is up to you to execute them. The
ultimate success of your goal attainment is in your hands, I am simply
the means to help you do so.

In addition, you understand that it is your responsibility to keep a copy
of all forms, receipts and payment confirmations for your records.

Please input your name and the date in the box below as your signature.

Please fill out the following form completely and to the best of your ability. While some
questions might seem a bit personal, the information is necessary in order for me to best
serve you as a coach. All aspects of a person's lifestyle greatly affect their efforts to
reaching their fitness goals and the more information I have before putting together and
implementing a training/nutrition program, the more effective our time will be spent.

nicki@nickic.com
916.580.4731