BETTER U Client Intake Center

Client Information

Basic details for your visit and follow-up.

First name

Last name

Date of birth

Mobile phone

Preferred name / pronouns

Address

City

State / ZIP

Initial Inquiry & Goals

Tell us what brought you to BETTER U.

What would you most like help with?

If this experience works well for you, what will be different 90 days from now?

How did you hear about us?

Is this your first visit?

Starting Point Assessment

A quick self-rating—not a medical evaluation.

Energy and stamina today (1–10)

Sleep and recovery today (1–10)

Ability to manage pressure today (1–10)

Confidence in following through today (1–10)

What feels like the biggest barrier right now?

General Health History

Information that helps us keep educational services and measurements appropriate.

Important: BETTER U provides education, coaching, and non-diagnostic measurement services. This questionnaire is not a medical diagnosis or treatment plan. For urgent symptoms or emergencies, call 911.

Have you experienced any of the following recently?

Dizziness or faintingChest pain or unusual shortness of breathRecent injury, surgery, or mobility limitationPregnant or possibly pregnantNone of these

List any relevant diagnosed conditions, injuries, implanted devices, or mobility concerns you want us to know about.

List medications or supplements you choose to disclose, including any that may affect balance, hydration, or exercise tolerance.

Allergies or sensitivities

Scope & Informed Acknowledgement

Clear expectations for BETTER U services.

BETTER U offers performance-development coaching, natural-health education, general wellness education, and non-diagnostic body measurement. Services do not include medical diagnosis, treatment, prescribing, psychotherapy, or emergency care. You remain responsible for your choices and may stop participation at any time.

I understand the educational and coaching scope described above and have had an opportunity to ask questions.I understand participation is voluntary and results cannot be guaranteed.I understand BETTER U is not an emergency or medical-care provider.

Body Measurement Consent

For your non-invasive three-dimensional body measurement session.

The scan records external body measurements and may generate posture and body-composition estimates. Results are educational tracking tools, not medical diagnoses. Close-fitting clothing may improve consistency. You may decline or stop the scan at any time.

Yes, I consent to the non-invasive body measurement session.No, I do not consent to a body measurement session.

Accessibility, balance, clothing, pregnancy, implanted-device, or mobility concerns

Emergency Contact

Someone we may contact if an urgent situation occurs during your visit.

Name

Relationship

Phone

Alternate phone

Privacy & Records Acknowledgement

How your intake information will be handled.

BETTER U will use the information you provide for scheduling, program delivery, safety, service records, and authorized follow-up. Access is limited to people who need it for those purposes. Electronic communication and ordinary email may carry privacy risks; avoid sending sensitive health information through regular email.

I acknowledge the privacy and records notice and understand how my information will be used.I agree to receive appointment confirmations and reminders by text. Message and data rates may apply; I may opt out.I agree to receive BETTER U educational updates by email. I may unsubscribe at any time.

Optional Photo & Testimonial Release

This choice is optional and does not affect services.

Choose one

No. Do not use my image, voice, story, or testimonial.Ask me first. I may consider a specific use after reviewing it.Yes. BETTER U may use approved photos, recordings, or testimonials for educational and promotional purposes. I may revoke future use in writing.

Review & Signature

Confirm that your answers are complete and accurate to the best of your knowledge.

Type your full legal name as your signature

Date

BETTER U staff initials (office use)

I confirm that I have reviewed this packet and that my answers are accurate to the best of my knowledge.

A typed name is used here to document acknowledgement on the Institute’s intake device. If a separate legally binding electronic signature is required, BETTER U will provide an approved signature process.

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