Please Register or before creating a health profile.

Health Profile Date:

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.

Overall (Please use print characters)

Overall (continued)

Diabetes

NOTE: If you are currently on a Sodium-Glucose Co-Transporter inhibitor (SGLT-2), do not start the weight loss method.

Cardiovascular Function

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

Kidney Function

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

Liver Function

Colon Function

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

Digestive Function

Ovarian/Breast Function

Endocrine Function

Neurological/Emotional Function

Inflammatory Conditions

Cancer

General

Allergies

Eating Habits

BREAKFAST
LUNCH
DINNER
OTHER
glasses per day
cups per day
for how many years?

Medications & Supplements

Please list all prescription medications and supplements you are currently taking.
Refer to the example in the first line

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.

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 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 or blue / identified as NPC or NPA on this form. Furthermore, I understand that I should not be undertaking or otherwise following the Ideal Proteintm Weight Loss Method 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 Weight Loss Method, ii) remain under the supervision of said medical doctor while I am on the Ideal Proteintm Weight Loss Method, 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 go on the Ideal Proteintm Weight Loss Method without specific supervision, such decision will be completely voluntary, and I release and discharge the clinic as well as Ideal Protein of America 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.

I confirm that the Ideal Proteintm Weight Loss Method has been explained to me, that I have had the opportunity to ask questions relating to the Ideal Proteintm 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 Proteintm 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 Proteintm Weight Loss Method.

Without limitation to the foregoing, I confirm that I have been advised that because the Ideal Proteintm 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 Proteintm Weight Loss Method.

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 on the Ideal Proteintm Weight Loss Method.

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 and guidelines of the American Arbitration Association, and I waive any rights to pursue any claims or causes of action in any court of law. Signed in (city/state), on this day of , 20.