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Client Self-Declaration & Nutrition Assessment Form

All information is confidential & securely stored

1Personal Information

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2Medical & Health History

Current Diagnosed Medical Conditions

3Dietary & Lifestyle Information

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4Goals & Preferences

5Self-Declaration

I hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that the nutritional advice and meal plans provided are based on the information I have disclosed and are not a substitute for professional medical care or diagnosis.

I acknowledge that the nutritionist and associated personnel are not liable or responsible for any unforeseen health issues, complications, or adverse reactions that may occur as a result of following the nutritional recommendations. I take full responsibility for my health decisions and understand that it is my duty to consult a physician for any medical concerns.

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