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Health Profile

Filter Type:
Full Name
Nickname (if any)
Email Address

Mailing Address
City, State & Zip


Daytime Phone
Evening Phone
Cell Phone

Age
Date of Birth
Profession

Current Weight
Current Height
Weight One Year Ago
Your Goal Weight
Lowest Adult Weight
... at age:
Highest Adult Weight
... at age:


Do you exercise? YES  NO
If yes, what kind of exercise & how often?

Have you ever been on a diet before? YES  NO
If yes, please specify which diet, and
why you think it didnít work for you
(e.g. too rigid, too much, hunger, etc.)

On a scale of 1 to 10, indicate what level of importance you give to losing weight
via Ideal Proteinís medically supervised weight loss method.
(1 is the lowest and 10 is the highest level)
 1  2  3  4  5  6  7  8  9  10



Family Life

What is your marital status? Married  Domestic Partner  Single  Separated  Divorced  Widowed


Do you have children at home? YES  NO
If yes, what are their ages?

Who does the meal planning, food shopping
& meal preparation in your home?



Medical Information

Your Physicians & Specialists
Please list your medical doctors & their specialties.
(This field will expand if you need more room.)


Diabetes
Do you have diabetes? YES  NO
If yes, are you under
the care of a physician?
 YES  NO
What type? Type I - Insulin Dependent (insulin injections)  Type II - Insulin Dependent (insulin & pills)  Type II - Non-Insulin Dependent (pills only)

Is your blood sugar
level monitored?
 YES  NO
If yes, by whom? Physician  Myself  Other
Specify
Do you tend to be Hypoglycemic? YES  NO

Are you taking any
diabetes medication?
 YES  NO
If yes, please list them here

Hypertension
Do you have high
blood pressure?
 YES  NO
If yes, do you have your
blood pressure checked?
 YES  NO
Are you under the care of a physician
for your high blood pressure?
 YES  NO

Are you taking any blood pressure medication? YES  NO
If yes, please list them here
Cardiovascular Health
Have you had a cardiovascular event? YES  NO
If yes, please specify
the event & date
Are you under the care of a physician? YES  NO

Are you taking any related medications? YES  NO
If yes, please list them here
Do you have a history of arrhythmia? YES  NO

Kidney Health
Have you been diagnosed
with kidney disease?
 YES  NO
Have you ever had Gout? YES  NO
Are you under the care of a physician for your kidney disease or gout?? YES  NO

Are you taking any related medications? YES  NO
If yes, please list them here

Liver Health
Do you have liver problems? YES  NO
If yes, please specify
Are you under the care of a physician? YES  NO

Are you taking any related medications? YES  NO
If yes, please list them here

Colon Health
Do you have any of these conditions? Irritable Bowel  Colitis  Diverticulitis or Diverticulosis  Crohn's Disease  Constipation


If yes, are you under the care of a physician? YES  NO
Are you taking any related medications? YES  NO
If yes, please list them here

Stomach & Digestive Health
Do you have any of these conditions? Acid Reflux  Gastric Ulcer  Heartburn  Celiac Disease
If yes, are you under the care of a physician? YES  NO
Are you taking any related medications? YES  NO
If yes, please list them here
Ovarian & Breast Health
Check off any that apply to you currently Irregular Periods  Heavy Periods  Fibrocystic Breasts  Hysterectomy  Menopause  Painful Periods  Amenorrhea  Uterine Fibroma  Cancer (Uterine or Breast)
Date of your last menstrual period
Are you under the care of a physician? YES  NO

Are you taking any related medications? YES  NO
If yes, please list them here

Thyroid Function
Do you have thyroid problems? YES  NO
If yes, are you under the care of a physician? YES  NO
Are you taking any related medications? YES  NO
If yes, please list them here

Emotional Evaluation
Do any of these apply to you? Depression  Anxiety  Panic Attacks  Bulimia (or history)  Anorexia (or history)
If yes, are you under the care of a physician? YES  NO

Are you taking any related medications? YES  NO
If yes, please list them here

Inflammatory Conditions
Do any of these apply to you? Migraines  Fibromyalgia  Lupus  Rheumatoid Arthritis  Osteoarthritis  Psoriasis  Chronic Fatigue Syndrome
Other Condition
Are you under the care of a physician? YES  NO

Are you taking any related medications? YES  NO
If yes, please list them here

Cancer
Do you have cancer? YES  NO
Are you in cancer remission? YES  NO
If yes, specify type & for how long?
Are you under the care of a physician? YES  NO

Are you taking any related medications? YES  NO
If yes, please list them here

Other Medical & Health Conditions
Are you pregnant? YES  NO
If yes, what is your expected date of delivery?
Are you breastfeeding? YES  NO

Are you generally fatigued, or do you have low energy? YES  NO
Do you get cold easily? YES  NO
Do you have cold hands/feet? YES  NO

Do you have any other health problems or concerns? YES  NO
If yes, please specify
Are you under the care of a physician? YES  NO
Are you taking any other medications not listed above? YES  NO
If yes, please list them here

Vitamins, Herbs & Supplements
Are you currently taking herbs, vitamins or supplements? YES  NO
Name & Reason for Taking
If yes, please list them here

Allergies - Food or Medication
Do you have any food or medication allergies? YES  NO
If yes, please list them here

Eating Habits
Breakfast
How often do you have breakfast? Usually  Sometimes  Occasionally  Rarely
Approximate Time
Examples of what you eat for breakfast
Do you have a snack before lunch? Usually  Sometimes  Occasionally  Rarely
Approximate Time
Examples of morning snacks

Lunch
How often do you have lunch? Usually  Sometimes  Occasionally  Rarely
Approximate Time
Examples of what you eat for lunch
Do you have a snack before dinner? Usually  Sometimes  Occasionally  Rarely
Approximate Time
Examples of afternoon snacks

Dinner
How often do you have dinner? Usually  Sometimes  Occasionally  Rarely
Approximate Time
Examples of what you eat for dinner
Do you have a snack before bed? Usually  Sometimes  Occasionally  Rarely
Approximate Time
Examples of before bed snacks

Other Choices
Do you prefer Sweet Foods  Salty Foods  Fatty Foods
Are you a vegetarian? YES  NO
How many glasses of water do you drink per day?
How many cups of coffee do you drink per day?

Do you smoke? YES  NO
If yes, how many per day & for how many years?
Do you drink alcohol? YES  NO
If yes, what kind, how much & how often?

CASH Scale: Compulsions (Cravings) - Appetite - Satiety - Hunger
Compulsions (Cravings): Feeling or urge to eat when not hungry, often associated with other emotions.
You are full. There is no food in sight. You get an urge to eat which cannot be repressed.
Never Occurs
 1  2  3  4  5  6  7  8  9  10
Always Occurs

Appetite: feeling of hunger stimulated by sight, sounds, smells or social cues.
You recently ate and feel full. You walk into a room. There is lots of food that looks and smells good. Everyone is having fun. You:
Never Eat More
 1  2  3  4  5  6  7  8  9  10
Always Eat More

Satiety: a feeling of fullness aquired during eating. When you eat, you usually:
Leave food on plate
 1  2  3  4  5  6  7  8  9  10
Go back for Thirds!
Finish first ---------- Go back for
plate only ------------ Seconds

Hunger: that feeling of a pain or ache in your stomach when it is really empty. It is a true pain or discomfort. How often do you feel hunger?
Never Hungry
 1  2  3  4  5  6  7  8  9  10
Always Hungry

You must take vitamins and minerals while you are on the Ideal Protein Weight Loss Method.
If you stop taking them, you may experience undesirable side effects.

Please initial here that you understand this.


If you are taking prescription medications,
are you interested in getting off any or all of them?
 YES  NO

If you have health problems not indicated on this health profile, please consult your physician.

Your signature (typed)
Date
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.