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1 Health Profile ALTH PROFILE Dietary consultation involves a health profile which purpose 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. General Last Name: First Name: Address: Apt/Unit: # City: State: Zip: Phone: Cell: Date of Birth: Age: Profession: Whom may we thank for referring you? Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age Maximum Weight: lbs. at age Height: Do you exercise? If yes, what kind? How often? Have you been on a diet before? If yes, please specify which diet and why you think it didn t work for you (e.g. too rigid, too much cooking involved, etc.): On a scale of 1 to 10, indicate what level of importance you give to losing weight via Ideal Protein s professionally supervised weight loss method (10 being the most important): 1
2 Family Life: What is your marital status? M S D W Other Do you have children? Number of children: Ages: Medical Information: Please list any physicians you see and their specialty: Diabetes: Do you have diabetes? (if no, skip to next section) If so, are you under the care of a physician? If so, 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? If so, by whom? Myself Physician Other (specify): Do you tend to be hypoglycemic? Cardiovascular Function: 2 Have you had a cardiovascular event? (if no, skip to next section) If so, please specify: How long ago? If so, are you under the care of a physician? Do you have a history of arrhythmia Have you been diagnosed with Congestive Heart Failure (CHF) Hypertension: Do you have high blood pressure? (if no, skip to next section) If so, do you have your blood pressure checked? If so, are you under the care of a physician?
3 Kidney Function: Have you been diagnosed with kidney disease? If so, are you under the care of a physician? Have you ever had Kidney Stones? Have you ever had Gout? Liver Function: Do you have liver problems? (if no, skip to next section) If so, please specify: If so, are you under the care of a physician? Colon Function: Do you have: Irritable Bowel Colitis Diarrhea Diverticulitis Crohn s disease Constipation? If so, are you under the care of a physician? Stomach/Digestive Function: Do you have: Acid Reflux Gastric Ulcer Heartburn Celiac Disease? If so, are you under the care of a physician? Ovarian/Breast Function: Check off the situations that apply to you currently: Irregular Periods Menopause Fibrocystic Breasts Painful Periods Hysterectomy Heavy periods Amenorrhea Uterine Fibroma Cancer (uterus, breast) If so, are you under the care of a physician? Please indicate the date of your last menstrual cycle: 3
4 Thyroid Function: Do you have thyroid problems? (if no, skip to next section) If so, are you under the care of a physician? Emotional Evaluation: Do any of the following apply to you? (if no, skip to next section) Depression Anxiety Panic Attacks Bulimia (or history of) Anorexia (or history of) If so, are you under the care of a physician? Inflammatory Conditions: Do any of the following apply to you? (if no, skip to next section) Migraines Fibromyalgia Rheumatoid Arthritis Lupus Osteoarthritis Chronic Fatigue Syndrome Psoriasis Other autoimmune or inflammatory condition: If so, are you under the care of a physician? General: Do you have Parkinson s disease? Do you have Cancer? Are you in Cancer remission? If so, please specify and indicate for how long: If so, are you under the care of a physician? Are you generally fatigued or have low energy? Are you pregnant? Are you breastfeeding? Do you get cold easily? Do you have cold hands/feet? Do you have other health problems? If so, please specify: If so, are you under the care of a physician? Are you taking any other medications not listed above? 4
5 Are you currently taking Vitamins, Herbs or Supplements? Vitamin, Herb or Supplement Name Reason Allergies: Do you have any food allergies? Do you have any medication allergies? Eating Habits: (please be as honest as possible so that we may better help you) Breakfast Do you have breakfast every morning? Examples: Do you have a snack before lunch? Examples: Lunch Do you have lunch every day? Examples: Do you have a snack before dinner? Examples: Dinner Do you have dinner every day? Examples: Do you eat a snack at night? Examples: Other: 5
6 Do you prefer: Sweet foods Salty foods Fatty foods Are you a vegetarian? How many glasses of water do you drink per day? glasses How many cups of coffee do you drink per day? cups Do you smoke? If yes, how many packs per day? for how many yrs? Do you drink alcohol? If yes, what, how much, and how often? CASH Scale: Compulsions or Cravings/Appetite/Satiety/Hunger Score each item on a 0 10 numbering scale. Each feeling represents a different part of the brain and different neurotransmitters Compulsions/Cravings Feeling or urge to eat when not hungry. You are full. There is no food in sight. You get an urge to eat which cannot be repressed. Appetite Never occurs Constant Feeling of hunger stimulated by sight, sounds, smells, or social cues. You recently ate and feel full. You walk into a room. There is food everywhere. It looks and smells good. Everyone is having fun. You: Never eat more Always eat more Satiety A feeling of fullness acquired during eating. When you eat, you usually: Leave food on plate one plate only second s thirds Hunger That feeling of a pain or ache in your stomach when really empty. This is a true pain or discomfort Never hungry Constant hunger 6
7 You must take vitamins and minerals while you are on the Ideal Protein Weight- Loss Method. If you stop taking them, you may experience undesirable side effects. (Client s initials) If you have health problems not indicated on this health profile, please consult your physician. Signature: Date: The signatory client hereby recognizes the veracity of the information provided herein and that he/she has made an informed decision to go on the Ideal Protein Weight Loss Method. *Disclaimer: A history of Congestive Heart Failure (CHF), Atrial Fibrillation, Parkinson s disease or Lithium prescription are ABSOLUTE CONTRAINDICATIONS to the Ideal Protein Weight Loss Method, regular or alternative. No non-medical Ideal Protein Clinic may ever accept such a person as a dieter. The only exceptions are licensed medical doctors (MD or DO). These practitioners may accept such patients, if in their professional judgment our protocol would be a benefit to their health. By accepting such a dieter, the physician will assume all responsibility for this patient s health as per their medical license. 05/01/12 7
Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age
Health Profile ALTH PROFILE Dietary consultation involves a health profile whose purpose is not to establish a diagnosis, but rather to determine a client s health status in order to guide his or her weight-loss
Do you exercise? Yes No If yes, what kind? How often?
HEALTH PROFILE Dietary consultation involves a health profile which purpose 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.
First Name. Profession. Weight lbs. Weight 1 year ago lbs. Min. Adult Weight lbs. at age Maximum Weight lbs. at age
Date Time Dietary consultation involves a health profile whose purpose 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
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Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months? I don t know
What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy Monticello Have you had labs (lipid profile & basic metabolic panel) done within
Are you a Christie registered patient? Yes No Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months?
What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy Are you a Christie registered patient? Yes No Monticello Have you had labs (lipid
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Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months? I don t know
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Health Profile. Last Name: First Name: Address: Apt/Unit: # City: State: Zip/Postal Code: Phone: Cell:
1 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
Weight 1 year ago (lb):
Health Profile 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
Apt. /unit: City: State: Zip Code:
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
Weight 1 year ago (lb):
Health Profile 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
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Weight 1 year ago (lb):
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