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Home Patient Forms Ideal Protein Health Profile Form

Ideal Protein Health Profile Form

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Ideal Protein – Health Profile -NEW FORM

1Demographics

2Overall

3Medical History

4chec

5Sign & Submit

Demographics
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.
- Personal info
- First Name*
- Last Name*
- Date of Birth*
  MM slash DD slash YYYY
- Mobile*
Contact info
- Address
- Apt./unit
- City
- State
- Zip Code
- Email*
- Age (NPC, if client is <18 years of age):
  Age (NPC, if client is <18 years of age)
- Profession
- How did you find us?

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Overall
Please mark the valid statement for you to determine whether you are a candidate for the Ideal Protein Weightloss Program.
Parameters
Current Weight (lb)
- Current Weight (lb)
Weight 1 year ago (lb)
- Weight 1 year ago (lb)
Minimum adult weight and how old were you
- Minimum adult weight (lb)
- At age
Maximum adult weight
- Maximum adult weight (lbs)
- At age
Height
- Height
- Do you exercise?
  - Yes
  - No
- If yes, what kind?*
- How often?
  - Daily
  - Weekly
  - Other
- If yes, what kind?*
- Have you been on a diet before?
  - Yes
  - No
- If yes, please specify which diet(s) and why you think it didn’t work for you (i.e., too rigid, too much cooking involved, etc.)*
- On a scale of 1—10, indicate what level of importance you give to losing weight with Ideal Protein’s professionally supervised weight loss method:
Lifestyle
- What is your marital status?*
  - Married
  - Single
  - Widow
  - Divorce
  - Other
- Other Relationships*
- How many children do you have?
- How old are they?
- Who does most of the cooking at home?*
  - Me
  - My partner
  - We don’t cook at home
  - Other
- Cooking at home (other)*
- On average, how many hours do you sleep per night?
- Your Doctor
- Who is your primary care physician (family doctor)?
- Please list any physicians you see and their specialty:
- Please list any physicians you see and their specialty (refer to medical information for list of disorders):
  Dr. Specialty Patient since Last visit

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Medical History
Please mark the valid statement for you to determine whether you are a candidate for the Ideal Protein Weightloss Program.
Diabetes
- Do you have Diabetes?*
  - Yes
  - No
- Which type?
  - Type I Diabetes (NPC) – Multiple Daily Insulin Injections (MDI) or Insulin Pump
  - Prediabetes – No Diabetes Medication, or only using Metformin
  - Type II Diabetes – No Medication
  - 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) – Sodium-Glucose Co-Transporter Inhibitors (SGLT2s)
  - Type II Diabetes (NPC) – Sulfonylureas, Thiazolidinediones (TZDs)
  - Type II Diabetes (NPC) – on Insulin
- 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 or Alternative Protocol on these medications. Speak to your coach.
- Is your blood sugar level monitored?
  - Yes
  - No
- If yes, how often?*
- If yes, by whom?
  - Myself
  - Physician
  - Other
- If other, please specify*
- Do you tend to be hypoglycemic?
  - Yes
  - No
Cardiovascular Function
- N/A
- Have you had any of the following conditions?
- Arrhythmia (NPA — if not on Rx meds)
  - Arrhythmia (NPA — if not on Rx meds)
- Please Specify date of occurrence?*
- Blood Clot (NPC)
  - Blood Clot (NPC)
- Please Specify date of occurrence?*
- Coronary Artery Disease (NPA
  - Coronary Artery Disease (NPA
- Please Specify date of occurrence?*
- Heart Attack (NPC)
  - Heart Attack (NPC)
- Please Specify date of occurrence?*
- Heart Valve Problem (NPA)
  - Heart Valve Problem (NPA)
- Please Specify date of occurrence?*
- Heart Valve Replacement (porcine/ mechanical) (NPA)
  - Heart Valve Replacement (porcine/ mechanical) (NPA)
- Please Specify date of occurrence?*
- Hyperlipidemia(High cholesterol/triglycerides)
  - Hyperlipidemia(High cholesterol/triglycerides)
- Please Specify date of occurrence?*
- Hyperkalemia (High potassium) (NPC)
  - Hyperkalemia (High potassium) (NPC)
- Please Specify date of occurrence?*
- Hypokalemia (Low potassium) (NPC)
  - Hypokalemia (Low potassium) (NPC)
- Please Specify date of occurrence?*
- Hypertension (High blood pressure) (NPC)
  - Hypertension (High blood pressure) (NPC)
- Please Specify date of occurrence?*
- Pulmonary Embolism (NPC)
  - Pulmonary Embolism (NPC)
- Please Specify date of occurrence?*
- Stroke or Transient Ischemic Attack (NPA)
  - Stroke or Transient Ischemic Attack (NPA)
- Please Specify date of occurrence?*
- History of Congestive Heart Failure (NPA)
  - History of Congestive Heart Failure (NPA)
- Please Specify date of occurrence?*
- Current Congestive Heart Failure (NPC)
  - Current Congestive Heart Failure (NPC)
- Please Specify date of occurrence?*
Have you ever had any type of heart surgery?*
- Yes (NPA)
- No
if yes, which type?*
Other conditions
Kidney Function
- N/A
- Have you had any of the following conditions?
- Kidney Disease (NPA)
  - Kidney Disease (NPA)
- Please Specify date of occurrence?*
- Kidney Transplant (NPA)
  - Kidney Transplant (NPA)
- Please Specify date of occurrence?*
- Kidney Stones
  - Kidney Stones
- Do you presently have kidney stones?
  - Yes (NPA)
  - No
- Since when:*
- If yes, what medication has been prescribed?*
- Gout
  - Gout
- Do you presently have gout?
  - Yes (NPA)
  - No
- Since when:*
- If yes, what medication has been prescribed?*
Liver Function
- N/A
- Have you ever had your gallbladder removed
  - Yes
  - No
- If NO, have you ever had gallstones/gallbladder attack (NPA)?
  - Yes (NPA)
  - No
- Do you have fatty liver?
  - Yes
  - No
- Do you have fatty liver with fibrosis or cirrhosis (NPA)?
  - Yes (NPA)
  - No
- Do you have any other liver conditions (NPA)?
  - Do you have any other liver conditions (NPA)?
- Please specify:
Colon Function
- N/A
- Do you have any of the following conditions?
- Constipation
  - Constipation
- Please Specify date of occurrence?*
- please specify?*
- Diarrhea
  - Diarrhea
- Please Specify date of occurrence?*
- please specify?*
- Irritable Bowel Syndrome
  - Irritable Bowel Syndrome
- Please Specify date of occurrence?*
- please specify?*
- Crohn’s Disease
  - Crohn’s Disease
- Please Specify date of occurrence?*
- please specify?*
- Diverticulitis
  - Diverticulitis
- Please Specify date of occurrence?*
- please specify?*
- Ulcerative Colitis
  - Ulcerative Colitis
- Please Specify date of occurrence?*
- please specify?*
Digestive Function
- N/A
- Do you have any of the following conditions?
- Digestive Function
  - Acid Reflux
  - Celiac Disease
  - Gastric Ulcer (NPA)
  - Gastroesophageal Reflux Disease (GERD)
  - Gluten intolerance
  - Heartburn
  - History of Bariatric Surgery (NPA)
- If yes, what type of Bariatric Surgery (NPA)?*
Ovarian/Breast Function
- N/A
- Do you currently have any of the following conditions?
- Amenorrhea
  - Amenorrhea
- Fibrocystic Breasts
  - Fibrocystic Breasts
- Heavy Periods
  - Heavy Periods
- Hysterectomy
  - Hysterectomy
- PCOS
  - PCOS
- Date of last menstrual cycle
  MM slash DD slash YYYY
- Irregular Periods
  - Irregular Periods
- Menopause
  - Menopause
- Painful Periods
  - Painful Periods
- Uterine Fibroma
  - Uterine Fibroma
- Infertility
  - Infertility
- Are you taking oral contraceptive pills?
  - Yes
  - No
- Are you breastfeeding? Not eligible for the Protocol.
  - Yes
  - No
- Are you pregnant?
  - Yes
  - No
Endocrine Function*
- N/A
- 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 told you have Metabolic Syndrome?
  - Yes
  - No
Neurological/Emotional Function
- N/A
- Do you have any of the following conditions?
- Neurological/Emotional Function
  - Alzheimer’s Disease (NPA)
  - Depression
  - Anorexia (or History of) (NPA)
  - Epilepsy (NPA)
  - Anxiety
  - Panic Attacks
  - Bipolar Disorder – ON Lithium. Not eligible for the Protocol.
  - Bipolar Disorder – NOT on Lithium (NPA)
  - Parkinson’s Disease (NPC)
  - Bulimia (or History of) (NPA)
  - Schizophrenia
- Other neurological/emotional issues?
Inflammatory Conditions
- N/A
- Do you have any of the following conditions?
- Inflammatory Conditions
  - Chronic Fatigue Syndrome
  - Multiple Sclerosis (MS) (NPA)
  - Fibromyalgia
  - Osteoarthritis
  - Lupus
  - Psoriasis
  - Migraines
  - Rheumatoid
  - Other autoimmune or inflammatory condition
Cancer
- N/A
- Do you have cancer (NPC)?
  - Yes(NPC)
  - No
- If yes, what type and where is it located?*
- Have you ever had cancer (NPA)?
  - Yes(NPA)
  - No
- If yes, what type and where is it located?*
- Is your cancer in remission (NPA)?
  - Yes(NPA)
  - No
- If yes, how long have you been in remission?*
  MM slash DD slash YYYY
General
- N/A
- Do you have any other health problems?
  - Yes
  - No
- If yes, please specify*
- Any other surgeries?
  - Yes
  - No
- If yes, please specify*
Allergies
- N/A
- Do you have any food allergies or sensitivities?
  - Yes
  - No
- If yes, please specify*

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Eating Habits
Please provide honest answers to the following questions so that we can help you.
Breakfast
- 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
Lunch
- 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
Dinner
- Do you have dinner every night?*
  - Always
  - Most days
  - Rarely
  - Never
- Approximate time
- Examples
- Do you have a snack at night?*
  - Always
  - Most days
  - Rarely
  - Never
- Approximate time
- Examples
Other
- Are you a vegan?*
  - Yes
  - No
  Not eligible for the Protocol. Strict vegans do not qualify due to too many dietary restrictions.
- Are you a vegetarian?*
  - Yes
  - No
- Do you smoke?*
  - Yes
  - No
- If yes, what do you smoke?*
- How many per day?*
- For how many years?*
- Do you drink alcoholic beverages?*
  - Yes
  - No
- 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 & Supplements
Please list all over-the-counter and prescription medications (including weight loss medications) and supplements you are currently taking. Refer to the example in the first line.
- I don’t take and medications and supplements
  - I don’t take and medications and supplements
*Or grams, mEq, or dosage unit your doctor prescribes.*
Name of medication* Milligrams per capsule* Number of capsules per day* Number of doses per day* Prescribing doctor* Reason for taking this medication*

*Or grams, mEq, or dosage unit your doctor prescribes.

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Sign & Submit
Confirmation of full health status disclosure by the client and agreement to arbitrate disputes
- *
  - I confirm that the information that I have provided to my Ideal ProteinTM Protocol service provider (the ”Clinic”) and that is recorded by me on this Ideal ProteinTM 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 / identified as NPC or NPA on this form. Furthermore, I understand that I should not be undertaking or otherwise following the Ideal ProteinTM Protocol if I have any of the said conditions or if I am currently taking any of the said medications unless i) I specifically consult with a medical doctor concerning my suitability to go on the Ideal ProteinTM Protocol, ii) remain under the supervision of said medical doctor while I am on the Ideal ProteinTM Protocol, and iii) 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 Clinic and iii) nevertheless chose to follow on the Ideal ProteinTM Protocol without specific supervision, such decision will be completely voluntary, and I, for myself and my successors, release and discharge the Clinic as well as Ideal Protein of America Inc., their parent companies, subsidiaries, and affiliates and each of 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 ProteinTM Protocol.
- *
  - I confirm that the Ideal ProteinTM Protocol has been explained to me, that I have had the opportunity to ask questions relating to the Ideal ProteinTM Protocol, that I have been provided with the answers to such questions, and that I understand the importance of strictly following the Ideal ProteinTM Protocol as explained to me verbally and in the materials provided to me, both before and during the period I will be following the Ideal ProteinTM Protocol.
- *
  - Without limitation to the foregoing, I confirm that I have been advised that because the Ideal ProteinTM Protocol limits the ingestion of certain foods, it is important that I consume the recommended vitamins and minerals while I am on the Ideal ProteinTM Protocol.
- *
  - I undertake to disclose immediately to the Clinic any and all changes in my health status, discomfort, symptoms, or other health concerns that I may experience while I am following the Ideal ProteinTM 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 state of residence, and I waive any rights to pursue any claims or causes of action in any court of law.
- Signed in
- on this
  MM slash DD slash YYYY
- Name of client (print)*
- Client Signature*
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Carlsbad

7220 Avenida Encinas, Suite 110-B
Carlsbad, CA 92011

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Office hours :

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Friday 9:30am to 2:00pm

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Name of medication*	Milligrams per capsule*	Number of capsules per day*	Number of doses per day*	Prescribing doctor*	Reason for taking this medication*

Ideal Protein Health Profile Form

Ideal Protein – Health Profile -NEW FORM

Demographics

Overall

Medical History

Eating Habits

Sign & Submit