Client Information

Full Name: _______________________________________________

Address: _________________________________________________

Telephone Number: ________________________________________

Email Address: ___________________________________________

Age: ___________

Height: ___________ cm

Current Weight: ___________ kg

Physical Activity

Please tick all that apply and indicate how many days per week:

☐ Walking ______ days per week

☐ Gym ______ days per week

☐ Running ______ days per week

☐ Other: _______________________ ______ days per week

Dietary Requirements

☐ Vegetarian

☐ Non-Vegetarian

☐ Vegan

☐ Pescatarian

☐ Other: __________________________________

Allergies / Food Intolerances

☐ Gluten-Free

☐ Lactose Intolerant

☐ Egg Allergy

☐ Nut Allergy

☐ Soy Allergy

☐ Shellfish Allergy

☐ Other: __________________________________

Existing Medical Conditions

Please provide details of any diagnosed medical conditions:

Disclosure & Nutrition Coaching Disclaimer

Mindful Eating is run by Zahra, who has completed a Professional Diploma in Nutrition and Dietetics.

Mindful Eating provides evidence-based nutrition coaching, education, and lifestyle support. Any information, recommendations, or resources shared are intended for general health and wellbeing purposes only.

Nutrition Coaching Disclaimer

Not Medical Advice

All information, guidance, and support provided are for educational and wellness purposes only and do not replace professional medical advice, diagnosis, or treatment.

No Medical Conditions Treated

Mindful Eating does not diagnose, treat, or manage medical conditions. If you have an existing health condition, you should seek advice from an appropriately qualified healthcare professional.

Individual Results May Vary

Results from nutrition coaching differ from person to person. No guarantees are made regarding weight loss, health outcomes, or physical changes.

Client Responsibility

You are responsible for your own health decisions and actions. By participating in coaching, you acknowledge that any lifestyle or dietary changes are undertaken voluntarily and at your own risk.

Qualifications and Scope

Services are limited to general nutrition guidance, healthy eating education, and lifestyle support. Nutrition coaching is not a substitute for medical, dietetic, or other regulated healthcare services.

Emergency Situations

Nutrition coaching is not suitable for medical emergencies. If you have urgent health concerns, please contact NHS 111 or emergency services as appropriate.

GDPR & Data Protection Consent

Mindful Eating is committed to protecting your personal data in accordance with the UK General Data Protection Regulation (UK GDPR).

By signing this form, you consent to Mindful Eating collecting, storing, and processing your personal information for the purpose of providing nutrition coaching services.

Your information will be:

• Stored securely and treated confidentially.
• Used only for nutrition coaching and client support purposes.
• Not shared with third parties without your consent unless required by law.
• Retained only for as long as necessary to provide services and meet legal obligations.

You may request access to your personal information at any time.

Programme Cancellation & Refund Policy

By enrolling in a Mindful Eating programme, you acknowledge and agree that refunds will not be issued once you have agreed to and commenced a programme. Should you choose to leave the programme before the agreed completion date, no refund will be provided for any remaining portion of the programme.

Client Declaration & Agreement

I confirm that:

☐ I have read and understood the Disclosure & Nutrition Coaching Disclaimer.

☐ I understand that nutrition coaching is educational in nature and is not medical treatment.

☐ I consent to Mindful Eating storing and processing my personal information in accordance with the GDPR statement above.

☐ I understand and accept the Programme Cancellation & Refund Policy.

Client Signature:

Signature: _______________________________________

Print Name: ______________________________________

Date: ___________________________________________