Health Profile

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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.

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.

 
Name *
Name
Address *
Address
Phone
Phone
DOB *
DOB
Do you exercise?
How often?
Have you been on a diet before?
What is your marital status?
Please list any physicians you see and their specialty (refer to medical information for list of disorders):
Diabetes
Do you have diabetes?
Which type?
Is your blood sugar level monitored?
If so, by whom?
Do you tend to be hypoglycemic?
Cardiovascular Function
Have you had any of the following conditions?
Please select one (if applicable):
Have you ever had any type of heart surgery?
Kidney Function
Have you had any of the following conditions:
Do you presently have gout?
If no, have you ever had gout?
Liver Function
Have you ever had any liver conditions?
Have you ever had a gallstone incident?
Do you have any of the following conditions:
Digestive Function
Do you have any of the following conditions:
Ovarian/Breast Function
Do you currently have any of the following conditions:
Are you taking oral contraceptive pills?
Are you pregnant?
Are you breastfeeding?
Endocrine Function
Do you have thyroid problems?
Do you have parathyroid problems?
Do you have adrenal gland problems?
Have you been told you have Metabolic Syndrome?
Neurological/Emotional Function
Do you have 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
Inflammatory Conditions
Do you have any of the following conditions:
Cancer
Do you have cancer? (NPC)
Have you ever had cancer? (NPC)
Is your cancer in remission? (NPC)
General
Do you have any other health problems?
Allergies
Do you have any food allergies or sensitivities?
Eating Habits (Please provide honest answers so that we can help you)
Breakfast
Do you have breakfast every morning?
Do you have a snack before lunch?
Lunch
Do you have lunch every day?
Do you have a snack before dinner?
Dinner
Do you have dinner every day?
Do you have a snack at night?
Other
Are you a vegan?
Strict vegans do not qualify due to too many dietary restrictions.
Are you a vegetarian?
Do you smoke?
Do you drink alcohol?
Medications & Supplements
Please list all prescription medications and supplements you are currently taking. Refer to the example in the first line.