Nutritional Assessment Consent Form

I, Courtney Hughes am a Certified Nutrition Educator. As a Nutrition Educator I am NOT A PHYSICIAN. This means I do not diagnose or treat disease. What I do is assist my clients in their desire to support the innate healing response of their bodies by suggesting an individualized selection of foods, herbs, nutritional supplements, and relaxation, visualization and exercise programs. I am a member of the National Association of Nutrition Professionals, the professional organization that sets standards, ethics and scope of practice for certified nutrition professionals.

 If you ever have any concerns about the nature of my services or our work together, please contact me right away. I recommend that you inform your medical doctor that you are receiving nutrition services.

CLIENT INFORMED CONSENT

I, the Client, understand that information provided on the relationship between nutrition and health is NOT meant to replace competent medical care or treatment for any health problem or condition. I understand that a Nutritional Assessment and Evaluation is not done to define health as it relates to disease but as it relates to wellness.

I, the Client, choose to improve my health by assuming greater self responsibility to reduce or eliminate unhealthy behaviors that are contrary to my well-being. The Surgeon General (1990) estimated that 7 out of the 10 leading causes of death in America are related to lifestyle habits, diet, smoking, lack of exercise, and substance abuse. They are the focal points of our work together.

I currently am____am not____under the care of a physician for a health problem or medical condition. If so, for what problem(s) or condition(s)?________________________________________

I, the Client, certify that I am here solely on my own behalf. I am not representing any other person, company, association, and/or on the behalf of any government agency.

Client Name:

__________________________________ 

___________________ Client Signature Date