Connect with us: (919) 998-6621

Women’s Health

Women's Health History Form

Confidential Health History
A simple Yes or No answer is perfect.
What foods did you eat often as a child?
What’s your food like these days?
DISCLAIMER OF HEALTH CARE RELATED SERVICES

The information and content on The Full Lotus Wellness Website or provided by email is not intended to replace an individual relationship with a qualified health care professional and is not intended as medical advice. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness encourage you to continue visiting with and being treated by your primary care physician or health care provider. Only a Licensed Medical Professional can diagnose certain ailments and prescribe treatments and medications for you. Do not ignore or delay seeking medical advice or treatment because of any information obtained from Full Lotus Wellness. Consult your own Medical Professional regarding all nutritional supplements to evaluate if the supplements could adversely affect or react with any medications or pre-existing conditions. Stop any food or supplement immediately if you have any type of adverse reaction. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness are not acting in the capacity of a doctor, licensed dietician, psychologist or any other licensed/registered professional. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness will not diagnose, treat, or cure in any manner, any disease, condition, or other physical or mental human ailment. By entering your email address you are also requesting and agreeing to subscribe to the Full Lotus Wellness e-newsletter, to which the above disclaimer also applies. Clarissa Kussin, Elijah Sacra and Delicious Food Daily Inc. (collectively "Full Lotus Wellness") expressly disclaims any responsibility or liability for any damages caused by a user’s reliance on any information contained or obtained via Full Lotus Wellness websites or emails. Full Lotus Wellness expressly disclaims all warranties, express or implied, of any kind with respect to the website or its emails, including but not limited to merchantability and fitness for a particular purpose. Full Lotus Wellness makes no representations or warranties, either express or implied, of any kind with respect to the information and content included on Full Lotus Wellness websites. You agree that the Delicious Food Daily Inc., its directors, officers, employees or other representatives shall not be liable for damages arising from the information and content viewed and obtained via Full Lotus Wellness. You agree that this limitation of liability is comprehensive and applies to personal injuries and all damages of any kind, including without limitation direct, indirect, incidental, general, special, punitive, compensatory and consequential damages.

NOTICE OF CONFIDENTIALITY

Delicious Food Daily, Inc., Full Lotus Wellness commits to keeping any information shared by you strictly confidential. Nothing in this form will be shared to to any third parties, except with the expressed permission of the client and unless it is required by law.

Your electronic signature indicates that you understand the above disclaimer and notice above before submitting this form.

Please wait...

Men’s Health History Form

Confidential Health History
What foods did you eat often as a child?
What’s your food like these days?
DISCLAIMER OF HEALTH CARE RELATED SERVICES

The information and content on The Full Lotus Wellness Website or provided by email is not intended to replace an individual relationship with a qualified health care professional and is not intended as medical advice. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness encourage you to continue visiting with and being treated by your primary care physician or health care provider. Only a Licensed Medical Professional can diagnose certain ailments and prescribe treatments and medications for you. Do not ignore or delay seeking medical advice or treatment because of any information obtained from Full Lotus Wellness. Consult your own Medical Professional regarding all nutritional supplements to evaluate if the supplements could adversely affect or react with any medications or pre-existing conditions. Stop any food or supplement immediately if you have any type of adverse reaction. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness are not acting in the capacity of a doctor, licensed dietician, psychologist or any other licensed/registered professional. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness will not diagnose, treat, or cure in any manner, any disease, condition, or other physical or mental human ailment. By entering your email address you are also requesting and agreeing to subscribe to the Full Lotus Wellness e-newsletter, to which the above disclaimer also applies. Clarissa Kussin, Elijah Sacra and Delicious Food Daily Inc. (collectively "Full Lotus Wellness") expressly disclaims any responsibility or liability for any damages caused by a user’s reliance on any information contained or obtained via Full Lotus Wellness websites or emails. Full Lotus Wellness expressly disclaims all warranties, express or implied, of any kind with respect to the website or its emails, including but not limited to merchantability and fitness for a particular purpose. Full Lotus Wellness makes no representations or warranties, either express or implied, of any kind with respect to the information and content included on Full Lotus Wellness websites. You agree that the Delicious Food Daily Inc., its directors, officers, employees or other representatives shall not be liable for damages arising from the information and content viewed and obtained via Full Lotus Wellness. You agree that this limitation of liability is comprehensive and applies to personal injuries and all damages of any kind, including without limitation direct, indirect, incidental, general, special, punitive, compensatory and consequential damages.

PERSONAL RESPONSIBILITY AND RELEASE OF HEALTH CARE RELATED CLAIMS

The Client acknowledges that the Client takes full responsibility for the Client’s life and well-being, as well as the lives and well-being of the Client’s family and children (where applicable), and all decisions made during and after this program. The Client expressly assumes the risks of the Program, whether or not such risks were created or exacerbated by the Coach. The Client releases the Coach, his/her heirs, executors, administrators and assigns, its officers, directors, shareholders, employees, teachers, lecturers, agents, health coaches and staff (collectively, the Releasees) from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law, admiralty or equity, which against the Releasees, the Client ever had, now has or will have in the future against the Releasees, arising from the Client’s past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of the Releasees.

NOTICE OF CONFIDENTIALITY

Full Lotus Wellness commits to keeping any information shared by you strictly confidential. Nothing in this form will be shared to to any third parties, except with the expressed permission of the client and unless it is required by law.

Your electronic signature indicates that you understand the above disclaimer and notice above before submitting this form.

Please wait...

Physical Activity Readiness Questionnaire {PAR-Q}

(Street Number, P.O. Box, etc.)

(Suite #, Building name etc.)

Emergency Contact 1
Emergency Contact 2
Client History

Sports/activities/recreation/movement experience.

Physical Activity Readiness Questionnaire

All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to help develop a program that addresses your needs, goals and is safe and effective. The PAR-Q is designed to identify adults for whom physical activity might not be appropriate or to determine medical caution for exercise.

Browse...

Upload the following:

  • Medical clearance from your physician
  • Any physical activity advice from your physician
Maximum size 10MB (jpg or pdf format). You can also email it to us at info (@) fulllotuswellness.com.

Health History
Please answer yes or no for the following questions:

I hereby understand the risks and have answered the information provided above to the best of my knowledge and ability.

RELEASE AND WAIVER OF LIABILITY

ASSUMPTION OF RISK AND INDEMNIFICATION AGREEMENT

The undersigned participant (hereinafter “PARTICIPANT”) in a training program, physical program, exercise program, class, or any other event (hereinafter collectively ‘TRAINING’) sponsored and/or conducted by, or on behalf of, “Elijah Sacra, Semper Fit, Incorporated, Full Lotus Wellness, and Delicious Food Daily”, its officers, directors, employees, related companies, successors, assigns, independent contractors, and/or training instructors (hereinafter collectively “PROVIDER”), will participate, now or in the future, in said TRAINING, including, but not limited to, engaging in physical activity and exercise associated with the TRAINING and utilizing equipment, instruction, services, facilities, and premises that are part of the TRAINING, entirely and expressly at PARTICIPANT'S own risk. Further, in express consideration for being permitted to participate in said TRAINING, the undersigned PARTICIPANT, on behalf of herself or himself, and all successors, heirs and assigns, agrees to completely and forever indemnify, release and hold harmless PROVIDER from any and all liability for injury, death, damages or losses of any type to PARTICIPANT and/or the personal property of the PARTICIPANT, and any claim, demand, lawsuit, injury, or damage of whatever type or nature (hereinafter collectively “CLAIM”), even if caused by acts or omissions, including but not limited to the passive or active negligence, of PROVIDER. The undersigned PARTICIPANT further expressly agrees that the foregoing RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNIFICATION AGREEMENT (hereinafter “RELEASE OF LIABILITY”) is intended to be as broad and inclusive as permitted by law, and that if any portions of this RELEASE OF LIABILITY are found invalid for any reason, agrees that the balance shall, notwithstanding, continue in full legal force and effect.
By signing below PARTICIPANT agrees that PARTICIPANT has read, understood and found acceptable this RELEASE OF LIABILITY, and that PARTICIPANT, or an authorized agent on his or her behalf, expressly agrees that PARTICIPANT is bound by this RELEASE OF LIABILITY.

Cancellation Policy- If a client must cancel a scheduled session, such cancellation must be made at least twenty-four hours (24) prior to the scheduled session or the client will be charged for the session.

Training Package Expiration Policy

There is a six month expiration date from the date of purchase on all training session packages.

Enter your first name and last name. Your name above signifies your print and digital signature to this agreement.

Please wait...

Child Health History Form

Confidential Health History
A simple Yes or No answer is perfect.
What’s your food like these days?
DISCLAIMER OF HEALTH CARE RELATED SERVICES

The information and content on The Full Lotus Wellness Website or provided by email is not intended to replace an individual relationship with a qualified health care professional and is not intended as medical advice. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness encourage you to continue visiting with and being treated by your primary care physician or health care provider. Only a Licensed Medical Professional can diagnose certain ailments and prescribe treatments and medications for you. Do not ignore or delay seeking medical advice or treatment because of any information obtained from Full Lotus Wellness. Consult your own Medical Professional regarding all nutritional supplements to evaluate if the supplements could adversely affect or react with any medications or pre-existing conditions. Stop any food or supplement immediately if you have any type of adverse reaction. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness are not acting in the capacity of a doctor, licensed dietician, psychologist or any other licensed/registered professional. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness will not diagnose, treat, or cure in any manner, any disease, condition, or other physical or mental human ailment. By entering your email address you are also requesting and agreeing to subscribe to the Full Lotus Wellness e-newsletter, to which the above disclaimer also applies. Clarissa Kussin, Elijah Sacra and Delicious Food Daily Inc. (collectively "Full Lotus Wellness") expressly disclaims any responsibility or liability for any damages caused by a user’s reliance on any information contained or obtained via Full Lotus Wellness websites or emails. Full Lotus Wellness expressly disclaims all warranties, express or implied, of any kind with respect to the website or its emails, including but not limited to merchantability and fitness for a particular purpose. Full Lotus Wellness makes no representations or warranties, either express or implied, of any kind with respect to the information and content included on Full Lotus Wellness websites. You agree that the Delicious Food Daily Inc., its directors, officers, employees or other representatives shall not be liable for damages arising from the information and content viewed and obtained via Full Lotus Wellness. You agree that this limitation of liability is comprehensive and applies to personal injuries and all damages of any kind, including without limitation direct, indirect, incidental, general, special, punitive, compensatory and consequential damages.

NOTICE OF CONFIDENTIALITY

Full Lotus Wellness commits to keeping any information shared by you strictly confidential. Nothing in this form will be shared to to any third parties, except with the expressed permission of the client and unless it is required by law.

Your electronic signature indicates that you understand the above disclaimer and notice above before submitting this form.

Please wait...

Women's Health History Form

Confidential Health History
A simple Yes or No answer is perfect.
What foods did you eat often as a child?
What’s your food like these days?
DISCLAIMER OF HEALTH CARE RELATED SERVICES

The information and content on The Full Lotus Wellness Website or provided by email is not intended to replace an individual relationship with a qualified health care professional and is not intended as medical advice. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness encourage you to continue visiting with and being treated by your primary care physician or health care provider. Only a Licensed Medical Professional can diagnose certain ailments and prescribe treatments and medications for you. Do not ignore or delay seeking medical advice or treatment because of any information obtained from Full Lotus Wellness. Consult your own Medical Professional regarding all nutritional supplements to evaluate if the supplements could adversely affect or react with any medications or pre-existing conditions. Stop any food or supplement immediately if you have any type of adverse reaction. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness are not acting in the capacity of a doctor, licensed dietician, psychologist or any other licensed/registered professional. Clarissa Kussin, Elijah Sacra and Full Lotus Wellness will not diagnose, treat, or cure in any manner, any disease, condition, or other physical or mental human ailment. By entering your email address you are also requesting and agreeing to subscribe to the Full Lotus Wellness e-newsletter, to which the above disclaimer also applies. Clarissa Kussin, Elijah Sacra and Delicious Food Daily Inc. (collectively "Full Lotus Wellness") expressly disclaims any responsibility or liability for any damages caused by a user’s reliance on any information contained or obtained via Full Lotus Wellness websites or emails. Full Lotus Wellness expressly disclaims all warranties, express or implied, of any kind with respect to the website or its emails, including but not limited to merchantability and fitness for a particular purpose. Full Lotus Wellness makes no representations or warranties, either express or implied, of any kind with respect to the information and content included on Full Lotus Wellness websites. You agree that the Delicious Food Daily Inc., its directors, officers, employees or other representatives shall not be liable for damages arising from the information and content viewed and obtained via Full Lotus Wellness. You agree that this limitation of liability is comprehensive and applies to personal injuries and all damages of any kind, including without limitation direct, indirect, incidental, general, special, punitive, compensatory and consequential damages.

NOTICE OF CONFIDENTIALITY

Delicious Food Daily, Inc., Full Lotus Wellness commits to keeping any information shared by you strictly confidential. Nothing in this form will be shared to to any third parties, except with the expressed permission of the client and unless it is required by law.

Your electronic signature indicates that you understand the above disclaimer and notice above before submitting this form.

Please wait...
Women’s Health April 14, 2016

Our Newsletter:

Get Free Email Update
It's FREE, delivered straight to your inbox!

Join Our Tribe:

How to Find Us:

By Appointment Only:
3319 Durham Chapel Hill Blvd.
Durham, NC 27707
Mail:
732 Ninth Street #581
Durham, NC 27705
Phone: (919) 530-0076

 
Email: info@fulllotuswellness.com

Giving Back:

10% of our revenue is donated to provide free holistic health and wellness services to Wounded, Ill and Injured service members, veterans... continue reading >>