Evolve180 / Ideal Northwest Health Profile

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Transcription:

Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: 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 1 2 3 4 5 6 7 8 9 10 Very important On a scale of 1 to 10, indicate your daily stress level: (circle one) No stress 1 2 3 4 5 6 7 8 9 10 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

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. 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

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

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

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