Ideal Health NOW Profile

If you are human, leave this field blank.

READ THIS FIRST. 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. Please look over the required questions first, and to complete this form please have your medical information accessible such as medication dosages and physicians address and phone, etc. You must complete the form in one setting and have a stable internet connection. Before submitting you can print a copy for your records if you desire. Please use the latest browser update if using Internet Explorer. We recommend using Firefox or Chrome browsers for a better experience. If you are having technical problems and need to manually complete the form a printable version can be found here- https://idealhealthnow.com/wp-content/uploads/2012/09/Health_Profile-1.pdf

Family Life

Do you have children? *

Number of Children

Ages of Children

Oldest to Youngest

Who does most of the cooking at home?

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

MEDICAL INFORMATION

Please supply the following information about your primary care physician.

Name *

First

Last *

Last

Phone *

Address *

Street

City *

City

State *

State

Zip *

Zip

Diabetes

Do you have diabetes? *

Type

Are you under the care of a physician?

Name, Address, and Phone of Physician treating your condition

Is your blood sugar monitored? *

By whom?

Are you taking any blood sugar medication? *

Please list medication and dosage taken.

Example: Metformin, Meglitinides, etc.

Do you tend to be hypoglycemic? *

HYPERTENSION

Do you have high blood pressure? *

Do you have a history of arrhythmia? *

Do you have your blood pressure checked? *

By whom?

Do you have high cholesterol? *

Are you under the care of a physician for blood pressure or cholesterol? *

Name, Address, and Phone of Physician treating your condition

Are you taking any hypertension or high cholesterol medication? *

Please list medication and dosage taken.

Example: Metformin, Meglitinides, etc.

KIDNEY HEALTH

Have you ever had kidney stones, kidney transplant or been diagnosed with kidney disease? *

Please check all that apply

Kidney Stones

Kidney Transplant

Kidney Disease

Are you under the care of a physician for kidney issues?

Name, Address, and Phone of Physician treating your condition

Are you taking any medication for kidney health? *

Please list medication and dosage taken.

Example: Metformin, Meglitinides, etc.

Do you presently have gout? *

If yes, what medication has been prescribed?

Have you ever had gout in the past?

yes

If yes, when?

LIVER HEALTH

Do you have, or have you ever had liver problems? *

Please Specify

Have you ever had a gallstone incident?

yes

Are you under the care of a physician?

Name, Address, and Phone of Physician treating your condition

Are you taking any liver medication? *

Please list medication and dosage taken.

Example: Metformin, Meglitinides, etc.

COLON HEALTH

Do you have one of the following? *

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

Are you under the care of a physician?

Name, Address, and Phone of Physician treating your condition

Are you taking any colon medication? *

Please list medication and dosage taken.

Example: Metformin, Meglitinides, etc.

STOMACH/DIGESTIVE HEALTH

Do you have one of the following conditions? *

If you have history of bariatric surgery, please specify what type?

Are you under the care of a physician?

Name, Address, and Phone of Physician treating your condition

Are you taking any medication for digestive health? *

Please list medication and dosage taken.

Example: Metformin, Meglitinides, etc.

Have you had a gastric bypass or other similar procedure? *

What year was the procedure performed?

THYROID / ENDOCRINE FUNCTION

Do you have thyroid problems? *

Do you have parathyroid problems?

yes

Do you have adrenal gland problems?

yes

Have you ever been told you have Metabolic Syndrome?

yes

If yes to any of the above questions please specify.

Are you under the care of a physician for thyroid?

Name, Address, and Phone of Physician treating your condition

Are you taking any thyroid medication? *

Please list medication and dosage taken.

Example: Metformin, Meglitinides, etc.

INFLAMMATORY CONDITIONS

Please Specify

Are you under the care of a physician for any of the above?

Name, Address, and Phone of Physician treating your condition:

Are you taking any medication for these conditions you checked above? *

Please list medication and dosage taken.

Example: Metformin, Meglitinides, etc.

CANCER

Do you have cancer currently? (NPC) *

If so, what type and where is it located?

Have you ever had cancer? *

yes

If so what type and where was it located?

Are you in cancer remission? *

For how long?

Are you under the care of a physician for cancer? *

Name, Address, and Phone of Physician treating your condition:

Are you taking any medication for cancer treatment? *

Please list medication and dosage taken.

Example: Metformin, Meglitinides, etc.

GENERAL

Are you generally fatigued or have low energy? *

Do you get cold easily? *

Do you have cold hands / feet? *

Do you have other health problems? *

For how long?

Please Specify

Are you under the care of a physician for other health problems not listed above? *

Name, Address, and Phone of Physician treating your condition:

Are you taking any other medications you have not listed? *

Please list medication and dosage taken.

Example: Metformin, Meglitinides, etc.

Are you taking any hormones or hormone modulators? *

Please list medication and dosage taken.

Are you taking any vitamins, herbs, or supplements? *

Please list

Please explain reason of use.

ALLERGIES

Do you have any food allergies? *

Please list

Are you gluten intolerant? *

Do you have any medication allergies? *

Please list medication allergies.

EATING HABITS: (please be as honest as possible so that we may better help you)

Do you eat breakfast?

Approximate Time

Examples:

Eggs, Cereal, Fruit, Energy Bars, etc.

Do you have a snack before lunch?

Approximate Time

Examples:

Fruit, Energy Bars, Candy, etc.

Do you eat lunch?

Approximate Time

Examples:

Fast Food, Sandwiches, Leftovers, Chips, Sodas, etc.

Do you eat a snack before dinner?

Approximate Time

Examples:

Sodas, Vegetables, Fruit, Energy Bars, Candy, etc.

Do you eat dinner?

Approximate Time

Examples:

Pastas, Out to Eat, Meats, Veggies, Sodas, Alcohol, etc.

Do you eat a snack at night?

Approximate Time

Examples:

Alcohol, Sodas, Leftovers, Chips, etc.

OTHER

Which do you prefer? *

Are you a vegetarian or vegan? Strict vegans do not qualify due to too many dietary restrictions. *

How many 8oz glasses of water do you drink daily? *

How many cups of coffee do you drink daily? *

Do you smoke? *

How many packs daily?

Example: 0.5, 2, etc.

For how many years?

Example: 5, 10, 13

Do you drink alcohol? *

Please explain how much and how often.

You must take vitamins and minerals, and abstain from alcohol while you are on the Ideal Protein Weight-Loss Method. If you stop taking the vitamins or drink alcohol you may experience undesirable side effects. 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.

Initials *

Digital Signature *

Date Signed *

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Ideal Health NOW Profile

General Information

Family Life

MEDICAL INFORMATION

Diabetes

CARDIOVASCULAR HEALTH:

HYPERTENSION

KIDNEY HEALTH

LIVER HEALTH

COLON HEALTH

STOMACH/DIGESTIVE HEALTH

OVARIAN/BREAST HEALTH

THYROID / ENDOCRINE FUNCTION

NEUROLOGICAL/EMOTIONAL FUNCTION

INFLAMMATORY CONDITIONS

CANCER

GENERAL

ALLERGIES

EATING HABITS: (please be as honest as possible so that we may better help you)

OTHER

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