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Health Declaration Form

Please fill out this form to receive nutrition advice from Koren.

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Disclaimer

Before starting any new diet and exercise program please check with your doctor and clear any exercise and/or diet changes with them before beginning. I do not claim to help treat or cure any condition or disease.

I cannot and do not guarantee that you will attain a specific or particular result, and you accept the risk that results differ for each individual. The health, fitness, and nutrition success depends on each individual’s background, dedication, desire, and motivation. As with any health-related program or service, your results may vary, and will be based on many variables, including but not limited to, your individual capacity, life experience, unique health and genetic profile, starting point, expertise, and level of commitment.

I expressly disclaim responsibility to any person or entity for any liability, loss, or damage caused or alleged to be caused directly or indirectly as a result of the use, application or interpretation of any material provided to you as the client.

Health declaration

Please fill out the following form.

Date of birth
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes
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