Nutrition Assessment

Consent Form

Name *
Gender *
Phone *
Assess your Physical Activity Level *
Please list all medical issues and include any medications you are currently taking, including any taken in the past 24months
I acknowledge that the purpose of this program is to help me improve my health, wellness and lifestyle. I am employing the services of Erika Vipond, Certified Holistic Nutritionist (CHN), so that I can obtain information and guidance about health factors within my own control (diet, hydration, lifestyle, fitness, wellness and other various lifestyle behaviours) in order to help support my health and wellness. I understand that Erika Vipond is a nutritional educator and does not dispense medical advice nor prescribe treatment. *