Health & Performance Consultation Form Please complete the form below to the best of your ability. You will be contacted shortly after the form is received.

Name

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Date

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Email

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Age

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OccupationDOB

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What Do You Want?Why?Notes

 

Do You Struggle With Any Of The Following? (Check All That Apply)

Energy/MotivationYes
PainYes
DigestionYes
SleepYes
ExerciseYes
Not Getting Enough Downtime (White Space)Yes
StressYes
DepressionYes
Cravings/OvereatingYes
Other

 

List Any Vitamins, Minerals, Supplements, or Herbs You Are Taking - Including Dosages

 

List Any Medications You Are Taking - Including Dosages & Length Of Time

 

Know Your Numbers

TestResultsDateNormsGoal
Cholesterol150-250 mg/dl
HDL45-90 mg/dl
LDL60-130 mg/dl
Cholesterol/HDL Ratio<3.5 f/ <4.5 m
Triglycerides<110 mg/dl
Glucose65-99 mg/dl
Hemoglobin A1C4% - 5.6%
Homocysteine4-10 umol/l
High Sensitive C-Reactive ProteinLow Risk < 1.0mg/l
Avg. Risk < 1.0-3.0mg/l
High Risk > 3.0mg/l
PSA Screening00.-4.00ng/ml
Thyroid-Stimulating Hormone
T3
T4
.35-5.50 ulu/ml
27%-47%
4-12 ug/dl
25-hydroxy Vitamin D Total25.0-80.0 ng/ml
Total Testosterone30-95 ng/dl Women
500-1200 ng/dl Men
Blood Pressure<120/80
Resting Heart Rate<65 bpm
Body Weight
Other

 

Additional Notes

 

Please Fill Out The Food Logs Below To Give Us An Idea Of Your Typical Day

DateMeal/TimeDescriptionWater (1 Block = 8 oz.)Exercise/Duration
Date:
Breakfast
Time:
H20

Superfoods
 Snack
Time:
 Lunch
Time:
 Snack
Time:
 Dinner
Time:
 Snack
Time:

 

DateMeal/TimeDescriptionWater (1 Block = 8 oz.)Exercise/Duration
Date:
Breakfast
Time:
H20

Superfoods
 Snack
Time:
 Lunch
Time:
 Snack
Time:
 Dinner
Time:
 Snack
Time:

 

On Target Living
Health and Performance Consulting Agreement

Agreement: This agreement is between On Target Living (OTL) and (Client)

Services: The Client understands that she/he is entering into this agreement to learn about natural health and better lifestyle practices and that she/he will be offered information about rest & rejuvenation, nutrition, and exercise as a guide to general health. All information provided by OTL is intended as information only. While people generally experience greater health and wellness as a result of embracing a healthier attitude, lifestyle, and diet, no guarantee of outcome is intended or implied. It is the sole responsibility of the Client to decide whether to act upon any information provided, and the responsibility for the consequences of such action or inaction are also solely borne by the Client. The Client understands that she/he should continue to see any medical doctors she/he is currently under the care of, and that any prescription medication should not be altered without first consulting the doctor who recommended it. The Client also understands nothing said, done, typed, printed or reproduced by OTL is intended to diagnose, prescribe, treat, or take the place of a licensed physician. It is the sole responsibility of the Client to provide complete and accurate information to OTL. Any inaccurate or omitted information as well as any misinformation may affect OTL’s assessment and/or advice.

Confidentiality: The information exchanged in consulting sessions will be kept confidential to the extent permissible by law. No information or ideas expressed will be shared with anyone except with the permission of the Client.

Proprietary Information: Any documents, materials, or information supplied by OTL during the course of consultations are to be held in the strictest confidence. Such documents, materials, or information are the sole property of OTL and may not be reproduced or communicated, in whole or in part, to any other person or organization without the express written consent of OTL.

Waiver and Hold Harmless: The Client shall indemnify, defend, and hold harmless OTL from and against all losses, liabilities, penalties, fines, damages and claims (including taxes), and all related costs and expenses (including reasonable attorneys’ fees and disbursements and costs of investigation, litigation, arbitration, mediation, settlement, judgments, interest, and penalties), arising from or in connection with consulting services provided by OTL.

Payment Plan: Payment is due no later than upon completion of each consulting session.

This agreement sets forth the entire agreement between OTL and the Client. By signing this agreement, the Client acknowledges that she/he has read and does understand this agreement and that she/he has not relied upon any representation or statement, written or oral, not set forth in this agreement, that her/his signature on this agreement is truly voluntary, and that she/he has entered into this agreement knowingly and willfully.

THE UNDERSIGNED HAS READ THE FOREGOING AGREEMENT AND FULLY UNDERSTANDS IT.

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