Ideal Protein Health Profile

Have you attend an Ideal Protein educational seminar?

YesNo

Before completing the Ideal Protein Health Profile, please attend an Ideal Protein Educational Seminar.

Seminars at hosted each Tuesday at 7pm

Signup for the next seminar below

Ideal Protein Education Seminar

Full Name*

First NameLast Name

Birth Date*

MonthDayYear

Age*

Gender*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState

Zip Code

E-mail*

Profession *

Referral Type *

Current weight*

Current height

Weight a year ago*

Minimum Adult Weight *

Maximum Adult Weight *

Do you currently exercise?*

YesNo

If yes please list what activities you currently do and how often

Have you ever been on a diet before?*

YesNo

If yes, what kind and why didn't they work for you?*

On a scale from 1 to 10, how important is losing weight with Ideal Protein to you?*

Marital Status*

How many Children do you have?*

List their ages *

Who does the cooking at home?*

On average how many hours do you sleep at night?*

Do you have a Primary Doctor?*

YesNo

Your Doctor's name*

First NameLast Name

Doctors Phone Number*

Area CodePhone Number

Do you have a Specialist?*

YesNo

Configurable list*

Do you have diabetes?*

NoYes, Type I- insulin Dependent (injections)Yes, Type II -non insulin dependent (Pills only)Yes, Type II -insulin dependent (pill and insulin)

Is your blood sugar monitored?*

YesNo

Who monitors it?*

MyselfDoctor

Do you tend to be hypoglycemic?*

YesNo

Have you had any of the following?*

Have you had any type of heart surgery? *

If yes, what kind?

Have you had any of the following conditions?*

Kidney Disease (NPA)Kidney Transplant (NPA)Kidney StonesN/A

Do you currently have gout?*

If yes, what medication was prescribed?

If no, have you ever had gout?

Have you ever had any liver conditions? *

If yes, please list:

Have you ever had a gallstone incident?*

Do you have any of the following conditions?*

If any other conditions please list, and give dates of events.

Do you have any of the following conditions?*

If so, what type of bariatric surgery?

Do you currently have any of the following conditions?*

Date of last menstrual cycle:

Are you taking oral contraceptive pills?*

YesNo

Are you currently pregnant?*

YesNo

Are you breastfeeding?*

YesNo

Do you have thyroid problems?*

YesNo

If yes, please specify :

Do you have parathyroid problems?*

YesNo

If yes, please specify:

Do you have adrenal gland problems?*

YesNo

Have you been told that you have metabolic syndrome?*

YesNo

Do you have any of the following conditions?*

Any other issues not listed:

Do you have any of the following conditions?*

Do you have cancer?*

YesNo

If yes, what type and where is located?

Have you ever had cancer?*

YesNo

If so, what type and where was it located?

Is your cancer in remission?

YesNo

If yes, how long have you been in remission?

Do you have any other health problems?*

YesNo

If yes, please specify:

Do you have any food allergies or sensitivities?*

YesNo

If yes, please specify:

Do you eat breakfast?*

YesSometimesNoNever

What time?

:HourMinutesAM/PM Option

Examples of breakfast:*

Do you have a snack before lunch?*

YesSometimesNoNever

If yes, what time?

:HourMinutesAM/PM Option

Examples of snacks: *

Do you eat lunch?*

YesSometimesNoNever

If yes, what time?

:HourMinutesAM/PM Option

Example of lunch: *

Do you have a snack before dinner?*

YesSometimesNoNever

if yes, What time?

:HourMinutesAM/PM Option

Examples of snacks *

Do you eat dinner?

YesSometimesNoNever

What time?

:HourMinutesAM/PM Option

Examples of dinner: *

Do you eat a snack before bed?*

YesSometimesNoNever

If yes, what time?

:HourMinutesAM/PM Option

Examples of snacks:

Are you Vegan?*

YesNo

Are you vegetarian?*

YesNo

Do you smoke?*

YesNo

If so, how many per day?

For how may years?

Do you drink alcohol?*

YesNo

If so, what and how often?

How many glasses of water do you drink in a day?*

How many cups of coffee do you drink in a day? *

How many energy drink do you drink in a day? (Red Bull, Monster, etc)*

Browse Files

Medications and Supplements*

Confirmation of full health status disclosure by the client and agreement to arbritrate disputes

I confirm that the information that i have provided to my Ideal Protein Protocol service provider (the clinic) and that is recoreded by me on this Ideal Protein 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 limitations to the foregoing, I specifically confirm that I do not have any of the conditions and that i am not taking any of the medicaitions specifically identified as NPC or NPA on this form. Furthermore, I understand that I should not be undertaking or otherwise following Ideal Protein Protocol if I have any of the said conditions or if I am currently taking any of the medications unless i) I specifically consult with a medical doctor concerning my suitability to go on the Ideal Protein Protocol,ii) remain under the supervision of said medical doctor while I am on the Ideal Protein Protcol, 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 medications, ii) have not disclosed same to the clinic and iii) nevertheless chose to follow on the Ideal Protein Protcol 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, liabilty, 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 Protein Protocol.

I confirm that the Ideal Protein Protocol has been explained to me, that I have had the opportunity to ask questions relating to the Ideal Protein Protocol, that I have been provided with the answers to such questions and that I understand the importance of strictly following the Ideal Protein 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 Protein Protocol.

Without limitations to the foregoing, I confirm that I have been advised that because the Ideal Protien Protocol limits the ingestions of certain foods, it is important that I consume the recommended vitamins and minerals While I am on the Ideal Protein Protocol.

I undertake to disclose immediatley to the Clinic any and all changes to my health status, discomfort, symptoms or other health concerns that I may experience while I am following he Ideal Protein 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 right to pursue any claims or causes of action to any court of law.

I agree to receive recurring SMS text messages from my representative (hereafter "coach") and Southern Health and Wellness to the provided mobile number and also agree to the terms and privacy policy. I understand that I may also be contacted by video and voice call by my Southern Health and Wellness coach. Message & Data rates may apply.

Full Name

First NameLast Name

Date

MonthDayYearHourMinutesAM/PM Option

Signature

Ideal Protein Health Profile

Lifestyle

Your Health

Diabetes

Cardiovascular Function

Kidney Function

Liver Function

Colon Function

Digestive Function

Ovarian/ Breast Function

Endocrine Function

Neurological/Emotional Function

Inflammatory conditions

Cancer

General

Allergies

Eating Habits

Other

Current Medications