Wardy Wellness Chiropractic - Chiropractor In El Paso, TX, USA

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Ideal Protein Patient Health Profile

Ideal Protein Health Profile

Dietary consultation involves a health profile whose purpose is not to establish a diagnosis, but rather to determine a clients health status in order to guide his or her weightloss plan. A client may be advised to seek medical advice based on his or her health profile.

General

Last Name *

First Name *

Address *

City *

State *

Zip *

Phone *

Cell

Email *

Date of Birth *

Age *

Profession

Whom may we thank you for referring you?

Weight *

Weight 1 Year ago *

Minimum adult weight *

at age *

Maximum adult weight *

at age *

Height *

Do you exercise? *

YesNo

If yes, what kind?

How often? *

Have you been on a diet before? *

YesNo

If yes, please specify which diet and why you think it didnt 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 profesionally supervised weight loss method 10 being the most important *

What is your marital status? *

MSDW

Do you have children? *

YesNo

Number of Children

Ages

Medical Information

Please list any physicians you see and their specialty *

Diabetes

Do you have diabetes? *

YesNo, If no skip to next section

If so, are you under the care of a physician?

YesNo

If so, which type?

Type I insulin dependentType II non insulin dependentType II insulin dependent

Is your blood sugar level monitored?

YesNo

If so, by whom?

MyselfPhysicianOther

If other, specify

Are you taking any medication?

YesNo

If so, please list

Do you tend to be hypoglycemic?

YesNo

Cardiovascular Function

Have you had a cardiovascular event? *

YesNo skip to next section

If so, please specify

How long ago?

If so, are you under the care of a physician?

YesNo

Are you taking any medication?

YesNo

If so, please list

Do you have a history of arrhythmia?

YesNo

Have you been diagnosed with congestive heart failure CHF?

YesNo

Hypertension

Do you have high blood pressure? *

YesNo skip to next section

If so, do you have your blood pressure checked?

YesNo

If so, are you under the care of a physician?

YesNo

Are you taking any medication?

YesNo

If so, please list

Kidney Function

Have you been diagnosed with Kidney disease? *

YesNo

If so, are you under the care of a physician?

YesNo

Are you taking any medication?

YesNo

If so, please list

Have you ever had kidney stones?

YesNo

Have you ever had gout?

YesNo

Liver Function

Do you have liver problems? *

YesNo skip to next section

If so, please specify

If so, are you under the care of a physician?

YesNo

Are you taking any medication?

Yes No

If so, please list

Colon Function

Do you have *

Irritable BowelColitisDiarrheaDiverticulosisCrohns DiseaseConstipation

If so, are you under the care of a physician?

YesNo

Are you taking any medication?

YesNo

If so, please list

Stomach/Digestive Function

Do you have *

Acid RefluxGastric UlcerHeartburnCeliac Disease

If so, are you under the care of a physician?

YesNo

Are you taking any medication?

YesNo

If so, please list

Ovarian/Breast Function

Check off the situations that apply to you currently *

Irregular PeriodsMenopauseFibrocystic BreastsPainful PeriodsHysterectomyHeavy PeriodsAmenorrheaUterine FibroidsCancer uterus, breast

If so, are you under the care of a physician?

Option 1Option 2Option 3

Are you taking any medication?

YesNo

If so, please list

Please indicate the date of your last mensrual cycle

Thyroid Function

Do you have thyroid problems? *

YesNo skip to next section

If so, are you under the care of a physician?

YesNo

Are you taking any medication?

YesNo

If so, please list

Emotional Evaluation

Do any of the following apply to you? if not, skip to the next section *

DepressionAnxietyPanic AttacksBulimiaAnorexia

If so, are you under the care of a physician?

YesNo

Are you taking any medication?

YesNo

If so, please list

Inflammatory Conditions

Do any of the following apply to you? if no, skip to the next section *

MigrainesFibromyalgiaRheumatoid ArthritisLupusOsteoarthritisChronic Fatigue SyndromePsoriasisOther autoimmune or inflammatory condition

If other, please list

If so, are you under the care of a physician?

YesNo

Are you taking any medication?

YesNo

If so, please list

General

Do you have Parkinsons disease? *

YesNo

Do you have cancer? *

YesNo

Are you in cancer remission?

YesNo

If so, please specify and indicate for how long

If so, are you under the care of a physician?

YesNo

Are you taking any medication?

YesNo

If so, please list

Are you generally fatigued or have low energy? *

YesNo

Are you pregnant? *

YesNo

Are you breast feeding?

YesNo

Do you get cold easily? *

YesNo

Do you have cold hands/feet? *

YesNo

Do you have other health problems? *

YesNo

If so, please specify

If so, are you under the care of a physician?

YesNo

Are you taking any medications not listed above?

YesNo

If so, please list

Are you currently taking Vitamins, Herbs, or Supplements? *

YesNo

If so, please specify name and reson for each

Allergies

Do you have any food allergies? *

YesNo

If so, please list

Do you have any medication allergies?

YesNo

If so, please list

Eating Habits (please be as honest as possible so we may better help you)

Breakfast

Do you have breakfast every morning? *

YesSometimesNever

If so, please specify approximate time and examples of what you eat:

Do you have a snack before lunch? *

YesSometimesNever

If so, please specify approximate time and examples of what you eat

Lunch

Do you have lunch every day? *

YesSometimesNever

If so, please specify approximate time and examples of what you eat

Do you have a snack before dinner? *

YesSometimesNever

If so, please specify approximate time and examples of what you eat

Dinner

Do you have dinner every day? *

YesSometimesNever

If so, please specify approximate time and examples of what you eat

Do you eat a snack at night? *

YesSometimesNever

If so, please specify approximate time and examples of what you eat

Other

Do you prefer *

Sweet FoodsSalty FoodsFatty Foods

Are you a vegetarian? *

YesNo

How many glasses of water do you drink per day? *

How many cups of coffee do you drink per day? *

Do you smoke? *

YesNo

If yes, how many packs per day?

And for how many years?

Do you drink alcohol? *

YesNo

If yes, what, how much, and how often?

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.

Client's Initials *

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

Electronic Signature *

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.

Contraindication Summary- Severe Kidney Disease, Severe Liver Disease, Congestive Heart Failure, Active Cancer or in remission less than 3 years, Cardiac/Cardiovascular Event within the last 6 months, History of Arrhythmia, Parkinson's Disease

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