Office Use. Stage of. Technique/Plan +/- Change. Establishing Your Health Goals. Date: Name: Age: Referred by:

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1 Establishing Your Health Goals Date: Name: Age: Referred by: Fill in your current Health Goals. Office Use Health Goals 1. Change +/- Stage of Change Technique/Plan FLT Personal Commitment Your level of commitment and adherence to the FLT program and lifestyle is a powerful predictor of reaching and maintaining your health goals. Package fees are to be paid in full at or before your first appointment as a gesture of your commitment. Cancellations must be made 24 hours in advance of your appointment. Less than 24 hour notice will result in forfeit of your paid appointment. Signature:

2 Diet Diary / Exercise Log Name: 1.) 2.) Please complete your "Diet Diary / Exercise Log" every day. Make note of the time you wake up. List and describe in detail all foods and drinks including the amount of each. Make note as to whether the food was fresh, frozen, canned, raw, cooked, baked, fried, etc. Note the time of each meal or snack. Be sure to list everything you eat or drink, including any condiments used (i.e. mayonaise, mustard, relish, etc.). 3.) Keep track of how much water you drink and list the amount in ounces in the section provided. Also note the type and amount of any other drinks you consume. 4.) Write down any activity or exercise you do in the section at the bottom, listing the kind of exercise you did and for how long you did it. 5.) 6.) Note any periods of relaxation and what kind of relaxation it was. Note the time you go to sleep. Day 1 Wake up: Morning Mid-Day Evening Water (ounces) Other Drinks (that are not listed with meals or snacks above) Activity/Exercise What kind: Date: Relaxation type: sleep time: MET1333 4/06

3 Diet Diary / Exercise Log Wake up: Morning Day 2 - Date: Day 3 - Date: Mid-Day Evening Water (ounces) Other Drinks (that are not listed with meals or snacks above) Activity/Exercise What kind: Relaxation type: sleep time: MET1333 4/06

4 Health Profile NAME DATE WEEK Rate each of the following symptoms based upon your typical health profile for: Past 30 days Past 48 hours Point 0 Never or almost never have the symptom 3 Frequently have it, effect is not severe 1 Occasionally have it, effect is not severe 4 Frequently have it, effect is severe Scale 2 Ocasionally have it, effect is severe HEAD EYES Headaches Faintness Dizziness Insomnia Watery or itchy eyes Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision (does not include nearor far-sightedness) DIGESTIVE TRACT JOINTS / MUSCLE Nausea, vomiting Diarrhea Constipation Bloated feeling Belching, passing gas Heartburn Intestinal/stomach pain Pain or aches in joints Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness EARS Itchy ears Earaches, ear infections Drainage from ear WEIGHT Binge eating/drinking NOSE Ringing in ears, hearing loss Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation ENERGY / ACTIVITY Craving certain foods Excessive weight Compulsive eating Water retention Underweight Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness MOUTH/ Chronic coughing THROAT Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen or discolored tongue, gums MIND Poor memory SKIN HEART LUNGS or lips Canker sores Acne Hives, rashes, dry skin Hair loss Flushing, hot flashes Excessive sweating Irregular or skipped heartbeat Rapid or pounding heartbeat Chest pain Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing EMOTIONS OTHER GRAND Confusion, poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speech Learning disabilities Mood swings Anxiety, fear, nervousness Anger, irritability, aggressiveness Depression Frequent illness Frequent or urgent urination Genital itch or discharge MET1341 4/06

5 FirstLine Therapy Targeted Nutrition Why should I use medical foods? Incorporating targeted nutrition with an effective lifestyle intervention can produce even greater objective results than dietary changes and lifestyle alone. In essence, medical foods can accelerate the process towards improved health and body composition. Medical foods are clinically demonstrated and specifically targeted to manage metabolic syndrome, insulin resistance and cardiovascular disease without the serious adverse effects of medications. Medical foods are convenient and cost effective. Ultra shakes and bars can be used as a meal replacement for times when you are rushed or in need of a healthy and satisfying alternative. Which medical food is right for me? As needed your Naturopathic Doctor or Lifestyle Educator will recommend the medical food that will best benefit your health. Clinical Application At-A-Glance Target: Metabolic Syndrome -altered body composition, central obesity, insulin resistance Formula: Ultra medical food and bars Metabolic Syndrome and Cardio-Vascular Disease -hypercholesterolemia, hypertriglyceridemia, hypertension Ultra Plus 360 medical food Ultra Plus medical food Cardio-Vascular Disease -hypercholesterolemia, hypertension Ultra Plus 360 Rice medical food Type 2 Diabetes -conditions associated with type 2 diabetes UltraGlycemX medical food Chronic Fatigue Syndrome UltraClear Plus Inflammatory Bowel Disease UltraInflamX Centre for Natural Medicine 1218 Lorette Ave Winnipeg, MB R3M 1W5 Tel