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Health Profile

Date:

Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client's health status in order to guide his or her weight loss plan. A client may be advised to seek medical advice based on his or her health profile.

Legend (For clinic use)

NPA - Needs Prescriber Approval
NPC - Needs Prescriber Care

1. Overall (Please use print characters)

First name:
Last name:
Address:
Apt./Unit:
City:
 
State:
Zipcode:
Phone:
Mobile:
Email:
Date of Birth:
Age:
Profession:
Referral:
Current Wait(Ib):
Weight 1year ago(Ib):
Minimum adult weight(Ib) :
At age:
Maximum adult weight(Ib) :
Height:
Do you exercise?
Yes   No
If yes, what kind?
How often?
Daily   Weekly
Other
Have you been on a diet before?
Yes   No

If yes, please specify which diet(s) and why you think it didn't work for you (i.e. too rigid, too much cooking involved, etc.)

On a scale of 1 to 10, indicate what level of importance you give to losing weight with Ideal Protein's professionally supervised protocol :(circle one)

Least important 1   2   3   4   5   6   7   8   9   10   Very important

What is your marital status? Married   Single   Widow   Divorce   Other
How many children do you have?
How old are they?
Who does most of the cooking at home?:
On average, how many hours do you sleep per night?
Who is your primary care physician (family doctor) ?

Please list any physicians you see and their speciality (refer to medical information for list of disorders):

Dr.
Speciality:
Patient since:
Last Visit:
Dr.
Speciality:
Patient since:
Last Visit:
Dr.
Speciality:
Patient since:
Last Visit:
Dr.
Speciality:
Patient since:
Last Visit:

2. Diabetes N/A

Do you have diabetes? Yes   No   If no, please skip to next section.
Which type?
Type I - Insulin-dependent (insulin injections only)
Type II - Non-insulin-dependent (diabetic pills)
Type II - Insulin-dependent (diabetic pills and insulin)
Is your blood sugar level monitored?
Yes   No
If so, how often?
If so, by whom? Myself   Physician   Other - please specify :
Do you tend to be hypoglycemic? Yes   No

Note: If you are currently on Sodium-Glucose Co-Transporter inhibitor medication (SGLT-2), which include Ebymect, Edistride, Forxiga, Invokana, Jardiance, Synjardy, Vokanamet and Xigduo, YOU CANNOT START OR BE ON IDEAL PROTEIN'S REGULAR PROTOCOL. Please speak to your coach about our Alternative Protocol.

3. Cardiovascular Function N/A

Have you had any of the following conditions?

Arrhythmia (NPA)
Blood Clot (NPA)
Coronary Artery Disease (NPA)
Heart attack (NPC)
Heart Value Replacement (porcine/mechanical) (NPA)
Hyperlipidemia (High cholesterol/triglycerides)
Hyperkalemia (High potassium) (NPA)
Hyperkalemia (Low potassium) (NPA)
Hypertension (High blood pressure) (NPA)
Pulmonary Embolism
Congestive Heart Failure (NPC) Please select one (if applicable)
History of Congestive Heart Failure
Current Congestive Heart Failure (NPC)
Have you ever had any type of heart surgery? Yes   No
If so, which type?
Other conditions:

If you have answered yes to any of the above conditions, please give all dates of occurrence:

4. Kidney Function N/A

Have you had any of the following conditions?

Kidney Disease (NPA)
Kidney Transplant (NPA)
Kidney Stones
Do you presently have gout? Yes   No   Since when:
If yes, what medication has been prescribed?
If no, have you ever had gout? Yes   No
If yes, when?

If yes to any of these events, please give dates of events. For mulitple events please specify:

5. Liver Function N/A

Have you ever had any liver conditions? Yes   No   Date:
If yes, please list:
Have you ever had a gallstone incident? Yes   No

6. Colon Function N/A

Do you had any of the following conditions?

Constipation
Crohn's Disease
Diarrhea
Diverticulitis
Irritable Bowel Syndrome
Ulcerative Colitis

If yes to any of these conditions, please give dates of events. For multiple events please specify:

7. Digestive Function N/A

Do you had any of the following conditions?

Acid Reflux
Celiac Disease
Gastric Ulcer (NPA)
Gulten intolerance
Heartburn
History of Bariatric Surgery (NPA)

If so, what type of Bariatric Surgery?

8. Ovarian/Breast Function N/A

Do you had any of the following conditions?

Amenorrhea
Fibrocystic Breasts
Heavy periods
Hysterectomy
Irregular periods
Menopause
Painful periods
Uterine Fibroma
Date of last menstrual cycle:
Are you taking oral contraceptive pills? Yes   No
Are you pregnant? Yes   No
Are you breastfeeding? Yes   No

9. Endocrine Function N/A

Do you have thyroid problems? Yes   No
If so, please specify:
Do you have parathyroid problems? Yes   No
If so, please specify:
Do you have adrenal gland problems? Yes   No
If so, please specify:
Have you been told you have Metabolic Syndrome? Yes   No

10. Neurological/Emotional N/A

Do you had any of the following conditions?

Alzheimer's disease
Anorexia (History of)
Anxiety
Bipolar disorder
Bulimia (History of)
Depression
Epilepsy (NPA)
Panic attacks
Parkinson's disease
Schizophrenia

Other issues:

11. Inflammatory Conditions N/A

Do you had any of the following conditions?

Chronic Fatigue Syndrome
Fibromyalgia
Lupus
Migraines
Other autoimmune or inflammatory condition
Multiple Sclerosis
Osteoarthritis
Psoriasis
Rheumatoid

12. Cancer N/A

Do you have cancer? (NPC) Yes   No
If so, what type and where is it located?
Have you ever had cancer? (NPC) Yes   No
If so, what type and where is it located?
Is your cancer in remission? (NPC) Yes   No
If so, how long have you been in remission?

13. General N/A

Do you have any other health problems? Yes   No
If so, please specify:

14. Allergies N/A

Do you have any food allergies or sensitivities? Yes   No
If so, please specify:

15. Eating Habits (Please provide honest answers so that we can help you)

Do you have breakfast every morning? Yes   Sometimes   No   Never
Approximate Time:
Examples:

Do you have a snack before lunch? Yes   Sometimes   No   Never
Approximate Time:
Examples:

Do you have lunch every day? Yes   Sometimes   No   Never
Approximate Time:
Examples:

Do you have a snack before dinner? Yes   Sometimes   No   Never
Approximate Time:
Examples:

Do you have dinner every day? Yes   Sometimes   No   Never
Approximate Time:
Examples:

Do you have a snack at night? Yes   Sometimes   No   Never
Approximate Time:
Examples:

Are you a vegan? Yes   No

Strict vegans do not qualify due to too many dietary restrictions.

Are you a vegetarian? Yes   No
Do you smoke? Yes   No
If so, how many per day?
For how many years?
Do you drink alcohol? Yes   No
If so, what and how often?
How many glasses of water do you drink per day?
How many cups of coffee do you drink per day?

16. Medications & Supplements

Please list all prescription medications and supplements you are currently taking.
Refer to the example in the first line.

Name of medication
Milligrams* per capsule
Number of capsules per day
Number of doses per day
Prescribing doctor
Reason for taking this medication

*Or grams, mEq or dosage unit your doctor prescribes.

Confirmation of full health status disclosure by the client and agreement to arbitrate disputes

I confirm that the information that I have provided to my Ideal Protein(TM) Protocolservice provider (the "Clinic") and that is recorded by me on this Ideal Protein(TM) Health Profile is true, complete and accurate and that I have not withheld or otherwise omitted, whether in whole or in part, any information concerning my health status. In this respect, I confirm that I have disclosed all past and present i) physical and/or mental health problems or concerns that I have experienced, ii) diagnoses and/or surgeries that I have had, and iii) medications and supplements that were prescribed to me or that I have taken.

Without limitation to the foregoing, I specifically confirm that I do not have any of the conditions and that I am not taking any of the medications specifically highlighted in purple/ identified as NPC or NPA on this form. Further more, I understand that I should any of the said medications unless i) specifically consult with a medical doctor concerning my suitability to go on the Ideal Protein(TM) Protocol, ii) remain under the supervision of said medical doctor while I am on the Ideal Protein(TM) Protocol, and iii) provide documentation confirming the foregoing.

I understand that if i) I have any of the aforementioned conditions or if I am currently taking any of the aforementioned medication, ii) have not disclosed same to the Clinic and iii) nevertheless chose to follow on the Ideal Protein(TM) Protocol without specific supervision, such decision will be completely voluntary, and I, for myself and my successors, release and discharge the Clinic as well as Ideal Protein of America Inc., their parent companies, subsidiaries and affiliates and each of their respective shareholders, directors, employees, agents, representatives, successors and assigns (collectively, the "Releasees") from any and all damages, liability, claims and causes of action of any nature whatsoever (including for injury, illness or death) that may result from such voluntary and informed decision of following the Ideal Protein (TM) Protocol.

I confirm that the Ideal Protein (TM) Protocol has been explained to me, that I have had the opportunity to ask questions relating to the Ideal Protein (TM) Protocol, that I have been provided with the answers to such questions and that I understand the importance of strictly following the Ideal Protein (TM) Protocol as explained to me verbally and in the materials provided to me, both before and during the period I will be following the Ideal Protein (TM) Protocol.

Without limitation to the foregoing, I confirm that I have been advised that because the Ideal Protein (TM) Protocol limits the ingestion of certain foods, it is important that I consume the recommended vitamins and minerals while I am on the Ideal Protein (TM) Protocol.

I undertake to disclose immediately to the Clinic any and all changes in my health status, discomfort, symptoms or other health concerns that I may experience while I am following the Ideal Protein (TM) Protocol.

I specifically agree that all claims against any of the Releasees that I may have or choose to make shall only be submitted to binding arbitration under the rules of the Arbitration Act or similar statue of may state of residence, and I waive any rights to pursue any claims or causes of actions in any court of law.

Signed in (city/state), on this
day of
Name of witness (print):
Name of client (print):






Client Signature Witness Signature
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