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 use print characters)
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 to 10, indicate what level of importance you give to losing weight with Ideal Protein's professionally supervised weight loss method: (clik one)
Who is your primary care physician (family doctor)?
Please list any physicians you see and their specialty (refer to medical information for list of disorders):
Is your blood sugar level monitored?
NOTE: If you are currently on a Sodium-Glucose Co-Transporter inhibitor (SGLT-2), do not start the weight loss method.
Have you had any of the following conditions?
Have you ever had any type of heart surgery?
If you have answered yes to any of the above conditions, please give dates of occurrence: all
Have you had any of the following conditions:
If so, what medication has been prescribed?
If no, have you ever had Gout?
If yes to any of these events, please give dates of events. For multiple events please specify:
Have you ever had any liver conditions?
If yes to any of these conditions, please give dates of events. For multiple events please specify:
Do you have any of the following conditions:
(Please provide honest answers so that we can help you)
How many glasses of
water do you drink per day?
How many cups of
coffee do you drink per day?
If so, what and how often?
Medications & Supplements
Please list all prescription medications and supplements you are currently taking.
Refer to the example in the first line
*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.