Evolve180 / Ideal Northwest Health Profile
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- Alaina Lee
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1 Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital Status: Married Single Divorced Widowed Do you have children? Yes No If yes, how many? Ages? EXERCISE AND EATING HABITS Have you been on a diet before? Yes No If yes, please give us the highlights and what worked/did not work for you: Do you currently exercise? Yes No If so, what kind? How often? On average, how many hours of sleep do you get per night? On a scale of 1 to 10, indicate what level of importance it is for you to lose weight: (circle one) Least important Very important On a scale of 1 to 10, indicate your daily stress level: (circle one) No stress Very stressed Do you follow any of the following diets? Vegan Vegetarian Other: 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? Evolve180 - Copyright 2018, All Rights Reserved pg. 1
2 Medical History HEALTH CONTACT Who is your primary care physician? 1. HEART AND VASCULAR CONDITIONS (please check all that apply) Hyperkalemia (high potassium) Arrhythmia/ A-Fib Hypokalemia (low potassium) Blood Clot On medication? Yes No Hypertension (high blood pressure) Coronary Artery Disease Pulmonary Embolism Heart Attack (within last 3 years) Stroke or Transient Ischemic Attack Heart Attack (prior to last 3 years) Congestive Heart Failure Heart Valve Problem Hyperlipidemia (high cholesterol) Heart Valve Replacement If yes to any of the previous events, please list the dates the events occurred; if they are current, let us know: Please note: if you have had a cardiac event in the past 6 months, we do require written approval from your physician prior to the beginning of your program Have you ever had any type of heart surgery? Yes No Explain: Medications (Heart and Vascular Conditions) 2. DIABETES Are you diabetic? (select which applies to you) No, I am not diabetic No, I am not diabetic, but I have a family history of type 2 diabetes I have been diagnosed as pre-diabetic Type 2 Non-Insulin Dependent Indicate Medications: Type 2 Insulin Dependent Indicate Medications: Type 1 Indicate Medications: Who measures your blood sugar levels? How frequently? How low are your severe blood sugar crashes? (mg/dl) Please note: insulin-dependent type 2 diabetes need to follow special instructions on the weight loss protocol. Your coach will explain. Evolve180 - Copyright 2018, All Rights Reserved pg. 2
3 3. LIVER FUNCTION Have you ever had any diagnosed liver conditions? Yes No If yes, please list: 4. KIDNEY FUNCTION (please check all that apply) Kidney Disease Kidney Transplant Kidney stones Gout If so, do you presently have gout? Yes No Since when? If yes, what medication is prescribed? 5. COLON & DIGESTIVE FUNCTION (please check all that apply) Acid Reflux Diverticulitis Celiac Disease Gastric Ulcer Constipation Gluten Intolerance diagnosed? Yes No Crohn s Disease Heartburn Diarrhea Irritable Bowel Syndrome Ulcerative Colitis If yes to any of the previous conditions, please specify dates of events: Do you have a history of bariatric surgery? Yes No If yes, what type and when? 6. ENDOCRINE FUNCTION Do you have thyroid problems? Yes No If yes, please specify: Do you have parathyroid problems? Yes No If yes, please specify: Do you have adrenal gland problems? Yes No If yes, please specify: Have you been diagnosed with Metabolic Syndrome? Yes No Medications (Endocrine Function) Evolve180 - Copyright 2018, All Rights Reserved pg. 3
4 7. INFLAMMATORY AND/OR AUTOIMMUNE CONDITIONS (please check all that apply) Fibromyalgia Lupus Migraines Multiple Sclerosis Osteoarthritis Psoriasis Rheumatoid arthritis Other Medications (Inflammatory / Autoimmune Conditions) 8. OVARIAN / BREAST FUNCTION (please check all that apply) Amenorrhea (no period) Fibrocystic breasts Heavy periods Hysterectomy Irregular periods Are you taking oral contraceptive pills? Are you pregnant? Yes No Are you breastfeeding? Yes No Menopause Painful periods PCOS (Polycystic Ovarian Syndrome) Uterine Fibroma Yes No (if yes, use back-up method) 9. CANCER Do you have cancer? Yes No If yes, please list what type and when: _ Do you have a history of cancer? Yes No If yes, please list what type and when: Evolve180 - Copyright 2018, All Rights Reserved pg. 4
5 10. NEUROLOGICAL / EMOTIONAL FUNCTION (please check all that apply) Alzheimer s disease Anorexia (history of) Anxiety Bipolar disorder Bulimia (history of) Other: Depression Epilepsy Panic attacks Parkinson s disease Schizophrenia Medications (Neurological / Emotional Function) 11. ALLERGIES Do you have any food allergies? Yes No If so, please list: Do you have any food sensitivities/ intolerances? Yes If so, please list: No 12. OTHER Do you have any other health concerns? Yes No If so, please specify: Evolve180 - Copyright 2018, All Rights Reserved pg. 5
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
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
Last Name: First Name: Address: Apt/Unit #: City: State: Zip: Best Contact Phone Number: Date of Birth: Age: Profession:
Health Profile Our 30/10 program is intended to help participants with their personal weight loss efforts. We are not a medical facility, and our staff cannot give you medical or psychological advice.
Health Profile. (Please Print) Last Name: First Name. Address: Apt/Unit: # City: State: Zip Code: Cell: Phone: Profession:
1 Health Profile 1. General Date: / / 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
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
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.
ITG Diet Health Status Intake Form
Health Status Intake Form Date: Last Name: First Name: D.O.B: Address: City: ST: ZIP Phone: Cell: Email: Age: HT: WT: BMI: Fat %: Occupation: Sex: M F Marital Status: M S D W How did you hear about the
Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age
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
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
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
Are you a Christie registered patient? Yes No Have you had labs (lipid profile & basic metabolic panel) done within 6-9 months?
What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy or Danville Are you a Christie registered patient? Yes No Have you had labs (lipid
Health Profile. Individual Initial Consultation Date: Time: Coach:
! 1 Approved Approved with restrictions Not Approved, see Dr. Matzner Orientation Class Date: Time: Individual Initial Consultation Date: Time: Coach: Health Profile Dietary consultation involves a health
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
CHIRO-MED.Excellence in Chiropractic Medicine
CHIRO-MED.Excellence in Chiropractic Medicine \~32()0 WI--:ST MAl STREE',V 1480 NORTH CRU~N MOUNT RD. 11I':U,EVILLE, IL 62226 O'FALLON, IL 62269 () I1
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
Weight Loss Profile. Do you exercise? Yes No If yes, what kind? How Often?
Weight Loss Profile Weight Loss 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
How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all
Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We
Weight 1 year ago (lb):
Health Profile Instructions For internal use by clinic only Date: Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine
Health Profile Instructions For internal use by clinic only
Health Profile Instructions For internal use by clinic only Client Library > Clinic Manual > Date: Dietary consultation involves a health profile. The purpose of the health profile is not to establish
Gender: M F Race: Caucasian African American Hispanic Other
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