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 or her weight loss plan. A client may be advised to seek medical advice based on his or her health profile.

Last name

First name

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone

Format: 1(860)739-0471

Mobile

Date of Birth

Age

Profession

Referral

Current weight (lb)

Height

Weight 1 year ago (lb)

Minimum adult weight (lb) / what age

Maximum adult weight (lb) / at age

Do you exercise?

Yes

If yes, what kind?

How often?

Daily

Weekly

Other

Have you been on a diet before?

Yes

N/A

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):

What is your marital status?

Married

Single

Divorce

Widow

Do you have children?

Yes

How many children do you have?

How old are they?

Who does most of the cooking at home?

On average, how many hours do you sleep per night?

Medical Information

Who is your primary care physician (family doctor)?

Please list any physicians you see and their specialty:

Do you have diabetes? (if no, skip to next section)

Yes

Which type?

Type I Diabetes (NPC) – Multiple Daily Insulin Injections (MDI) or Insulin Pump

Prediabetes - No Diabetes Medications, or only using Metformin

Type II Diabetes – No Medications

Type II Diabetes – Medications such as Metformin; GLP-1 agonists; DPP-4 Inhibitors

Type II Diabetes (NPC) – Sodium-Glucose Co-Transporter Inhibitors (SGLT2s)

Type II Diabetes (NPC) – Sulfonylureas, Thiazolidinediones (TZDs)

Type II Diabetes (NPC) – on Insulin

Is your blood sugar level monitored?

Yes

If yes, how often?

If yes, by whom?

Myself

Physician

Other

If other, please explain

Do you tend to be hypoglycemic?

Yes

Have you ever had ANY type of heart surgery?

Yes (NPA)

If yes, which type?

Other conditions:

If you have answered yes to any of the above conditions, please give all dates of occurrence;

Have you had Kidney Disease (NPA)?

Yes

Have you had a Kidney Transplant (NPA)?

Yes

Have you had Kidney Stones?

Yes

Do you presently have kidney stones?

Yes (NPA)

Since when

Do you have Gout?

Yes

Do you presently have gout?

Yes (NPA)

Since when?

If yes, what medication has been prescribed?

If yes to any of these event, please give the dates of events. For multiple events please specify:

Have you ever had your gallbladder removed

Yes

If NO, have you ever had gallstones/gallbladder attack(NPA)?

Yes (NPA)

Do you have fatty liver?

Yes

Do you have fatty liver with fibrosis or cirrhosis (NPA)?

Yes (NPA)

Do you have any other liver conditions (NPA)?

Yes

please specify.

If yes to any of these events, please give dates of events. For multiple events please specify:

If yes, what type of bariatric surgery (NPA)?

Date of last menstrual cycle:

Are you on oral contraception pills?

Yes

Are you pregnant?

Yes

Are you breastfeeding?

Yes

Do you have thyroid problems?

Yes

If yes, please specify:

Do you have parathyroid problems?

Yes

If yes, please specify:

Do you have adrenal Gland problems?

Yes

If yes, please specify:

Have you been told you have Metabolic Syndrome?

Yes

Other issues:

Do you have Cancer(NPC)?

Yes (NPC)

If yes, what type and where is it located?

Have you ever had Cancer (NPA)?

Yes (NPA)

If yes, what type and where is it located?

Is your Cancer in remission(NPA)?

Yes (NPA)

If yes, how long have you been in remission?

Do you have any other health problems?

Yes

If yes, please specify:

Do you have any other health problems?

Yes

If yes, please specify:

Do you have any food allergies or sensitivities?

Yes

If yes, please specify:

Eating Habits:

(please provide honest answers to the following questions so that we can help you)

Do you have breakfast every morning?

Always

Most days

Rarely

Never

Approximate Time:

Examples:

Do you have a snack before lunch?

Always

Most days

Rarely

Never

Approximate Time:

Examples:

Do you have lunch every day?

Always

Most days

Rarely

Never

Approximate Time:

Examples:

Do you have a snack before dinner?

Always

Most days

Rarely

Never

Approximate Time:

Examples:

Do you have dinner every day?

Always

Most days

Rarely

Never

Approximate time:

Examples:

Do you eat a snack at night?

Always

Most days

Rarely

Never

Approximate time:

Examples:

Are you a vegan?

Yes

Strict vegans do not qualify due to too many dietary restrictions.

Are you a vegetarian?

Yes

Do you smoke?

Yes

If yes, what do you smoke?

How many per day?

for how many years?

Do you drink alcoholic beverages?

Yes

If yes, what and how often?

How many glasses of water do you drink per day?

How many cups of coffee do you drink per day?

Medications

Medication List

Dear Client: Please list all prescription medications and supplements that you are currently taking and answer the following questions about each. • Name of Medication • How many mg is each tablet? • How many tablets do you take each day? • How often do you take a dose? • Prescribed by whom? • Why do you take this medication?

DISCLAIMER

Confirmation of Full Health Status Disclosure by the Client and Agreement to Arbitrate Disputes

I confirm that the information that I have provided and that is recorded by me on this Ideal Protein™ Health Profile is true, complete and accurate and that I have not withheld or otherwise omitted, whether in whole or in part, any information concerning my health status. In this respect, I confirm that I have disclosed all past and present i) physical and/or mental health problems or concerns that I have experienced, ii) diagnoses and/or surgeries that I have had, and iii) medications and supplements that were prescribed to me or that I have taken.

Without limitation to the foregoing, I specifically confirm that I do not have any of the conditions and that I am not taking any of the medications specifically highlighted in purple or blue / identified as NPC or NPA on this form. Furthermore, I understand that I should not be undertaking or otherwise following the Ideal Protein™ Weight Loss Method if I have any of the said conditions or if I am currently talking any of the said medications unless i) I specifically consult with a medical doctor concerning my suitability to go on the Ideal Protein™ Weight Loss Method, ii) remain under the supervision of said medical doctor while I am on the Ideal Protein™ Weight Loss Method, and iii) and
provide documentation confirming the foregoing.

I understand that if i) I have any of the aforementioned conditions or if I am currently taking any of the aforementioned medication, ii) have not disclosed same to the center and iii) nevertheless chose to go on the Ideal Protein™ Weight Loss Method without specific supervision, such decision will be completely voluntary, and I release and discharge the center as well as Laboratoires C.O.P. Inc., its parent companies, subsidiaries and affiliates and their respective shareholders, directors, employees, agents, representatives, successors and assigns (collectively, the “Releasees”) from any and all damages, liability, claims and causes of action of any nature whatsoever (including for injury, illness or death) that may result from such voluntary and informed decision of following the Ideal Protein™ Protocol.

I confirm that the Ideal Protein™ Weight Loss Method has been explained to me, that I have had the opportunity to ask questions relating to the Ideal Protein™ Weight Loss Method, that I have been provided with the answers to such questions and that I understand the importance of strictly following the Ideal Protein™ Weight Loss Method as explained to me verbally and in the materials provided to me, both before and during the period I will be following the Ideal Protein™ Protocol.

Without limitation to the foregoing, I confirm that I have been advised that because the Ideal Protein™ Weight Loss Method limits the ingestion of certain foods, it is important that I consume the recommended vitamins and minerals while I am on the Ideal Protein™ Protocol.

I undertake to disclose immediately to the center any and all changes in my health status, discomfort, symptoms or other health concerns that I may experience while I am on the Ideal Protein™ Protocol.

I specifically agree that all claims against any of the Releasees that I may have or choose to make shall only be submitted to binding arbitration under the rules of the Arbitration Act or similar statute of my province of residence, and I waive any rights to pursue any claims or causes of action in any court of law.

By clicking I Accept, you confirm that you have read the terms and conditions, that you understand them and that you agree to be bound by them.

I agree

A completed health profile is REQUIRED FOR PARTICIPATION FOR OUR PROGRAM.

All health profiles must be resubmitted if the first appointment is not within two months of health profile submission.

Click HERE to download and print your health profile form to bring with you to the office on your first visit.
OR fill out the form online below.

A completed health profile is REQUIRED FOR PARTICIPATION FOR OUR PROGRAM.

All health profiles must be resubmitted if the first appointment is not within two months of health profile submission.

Click HERE to download and print your health profile form to bring with you to the office on your first visit. OR fill out the form online below.

Click HERE to download and print your health profile form to bring with you to the office on your first visit.
OR fill out the form online below.