Health Intake

*All questions require a Yes, No, or N/A response.

- Step 1 of 6

Please select if you have or have had any of the following conditions or circumstances:

Please select if you have or have had any of the following conditions or circumstances: *

Currently Undergoing Cancer Treatment
Severe Liver Disease
Severe Kidney Disease
Diagnosis of Parkinson's
Currently on Lithium Therapy
Alzheimer’s Disease
History of Congestive Heart Failure
Heart Attack within 6 Months
Strict Vegan Lifestyle
Currently Pregnant
Currently Breast Feeding
None of These Conditions Apply

Clients with any of the medical conditions listed below will be sent to their primary care doctor or specialist along with the Ideal Wellness NW Protocol Overview and the Authorization to Use Protected Health Information medical release form.

Please select if you have or have had any of the following conditions or circumstances: *

Arrhythmia (Abnormal Heart Rhythm)
Kidney Transplant
Blood Clot
Gastric Ulcer
Coronary Artery Disease
History of Bariatric Surgery
Heart Valve Problem
Epilepsy
Heart Valve Replacement
Hyperkalemia (High Potassium Level)
History of Heart Attack (Cardiologist Approval)
Hypokalemia (Low Potassium Level)
Pulmonary Embolism
Stroke or Transient Ischemic Attack (TIA)
History of cancer - 5 years or less
History of cancer - More than 5 years
Kidney Disease
Child Under Age 17 (Pediatrician Approval)
None of these conditions apply

Do you have a surgery within the next month? *

Do you have a vacation scheduled within the next month? *

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Health Profile

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.

1. Overall

Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Best Phone *

Email *

Biological Gender

Male
Female

Date of Birth *

Height *

Lowest Adult Weight (lbs): *

Highest Adult Weight (lbs): *

Profession: *

Do you exercise? *

If you have tried to lose weight before 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 the level of importance you give to losing weight with Ideal Wellness’ professionally supervised weight loss method (choose one):

Importance: 1

What is your marital status? *

Other:

How many children do you have? *

How old are they? *

If none, N/A

Who does the cooking in your home? *

If not you, is the cook supportive of your weight loss journey? *

Who is your primary care physician (family doctor)? *

Specialty

Patient since:

Specialty

Patient since:

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Eating Habits

Are you a vegetarian? *

Are you a Vegan? *

Do you drink alcohol? *

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

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

What are the top three items you eat for Breakfast? *

What are the top three items you eat for Lunch? *

What are the top three items you eat for Dinner? *

What are the top three items you eat for Snacks? *

2. Diabetes

Do you have diabetes? *

Which type?

Is your blood sugar monitored?

By whom?

Myself
Physician
Both

Do you tend to be hypoglycemic?

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

3. Cardiovascular Function.

Have you ever had any of the following conditions: *

Arrhythmia
Blood Clot
Coronary Artery Disease
Heart Attack
Heart Valve Problem or Replacement
Congestive Heart Failure
Hyperkalemia (High potassium) (NPA)
Hypokalemia (Low potassium)
Hypertension (High blood pressure)
Pulmonary Embolism
Stroke or Transient Ischemic Attack
Hyperlipidemia (High cholesterol/triglycerides)
History of Congestive Heart Failure
Current Congestive Heart Failure
None of These Conditions Apply

Have you ever had any type of heart surgery? *

Other conditions:

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

Please check this box to indicate you have read this section *

I have read and completed this section

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4. Kidney Function

Have you had any of the following conditions: *

Kidney Disease (NPA)
Kidney Transplant (NPA)
Kidney Stones (NPA)
None of these conditions

Do you presently have gout? *

Have you ever had gout? *

5. Liver Function

Have you ever had any liver conditions? *

Date

Have you ever had a gallstone incident? *

6. Colon Function

Do you have any of the following conditions: *

Constipation
Crohn’s Disease
Diarrhea
Diverticulitis
Irritable Bowel Syndrome
Ulcerative Colitis
N/A

Please give date(s) of event(s):

7. Digestive Function

Do you have any of the following conditions: *

Acid Reflux
Gluten intolerance
Celiac Disease
Heartburn
Gastric Ulcer
History of Bariatric Surgery
N/A

Please check this box to indicate you have read this section *

I have read and completed this section

8. Ovarian/Breast Function

Do you have any of the following conditions: *

Amenorrhea
Irregular Periods
Fibrocystic Breasts
Menopause
Heavy Periods
Hysterectomy
Uterine Fibroma
None of These Conditions Apply

Date of last menstrual cycle *

Are you taking oral contraceptive pills? *

Are you pregnant? *

Are you breastfeeding? *

9. Endocrine Function

Do you have thyroid problems? *

Do you have parathyroid problems? *

Do you have adrenal gland problems? *

10. Neurological/Emotional Function

Do you have any of the following conditions: *

Alzheimer’s disease
Depression
Anxiety
Epilepsy
Bipolar Disorder
Parkinson’s disease
Schizophrenia
Anorexia (History of)
Bulimia (History of)
None of These Conditions Apply

Are you on Lithium Therapy? *

Other issues:

Please check this box to indicate you have read this section *

I have read and completed this section

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11. Inflammatory Conditions

Do you have any of the following conditions: *

Multiple Sclerosis
Fibromyalgia
Osteoarthritis
Lupus
Psoriasis
Migraines
Rheumatoid
Chronic Fatigue Syndrome
None of These Conditions Apply

Other autoimmune or inflammatory condition:

Please check this box to indicate you have read this section *

I have read and completed this section

12. Cancer

Do you have cancer? *

Have you ever had cancer? *

Is your cancer in remission? *

13. Other

Do you have any other health problems? *

Please explain:

14. Allergies

Do you have any food allergies or sensitivities? *

List the medications you are currently taking

Name, Milligrams per capsule, # of Capsules/Day, # of doses per day, Prescribing Doctor, Reason for Medication

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16. Goals & Habits

What is your goal and why now? *

How long do you anticipate coming to Ideal Wellness NW? *

What is your motivating factor right now? (Your, “I need a change” moment?) *

Are you open to changing the food environment in your home? *

Do you have small children or others you cook for? *

Are you open to changing the food your kids eat too? (i.e. more vegetables, healthier options) *

What will be your biggest challenge with this? *

Check favorite items you like in everyday meals:

Are you more: *

Salt & Savory
Sweet Tooth

Spices: *

Hot
Mild

Proteins *

Chicken
Steak
Seafood
Tofu
Other

Veggies *

Greens
Celery
Cucumber
Tomatoes
Bell Peppers
Mushrooms
Zucchini
Cauliflower
Broccoli
Onions

How do you see yourself getting through the next 3-10 holidays/ events, while on phase 1 protocol? *

Share 3 food triggers: (vacations, sporting events, arguments, etc.) *

Do you feel you have sabotagers or food pushers in your life? *

Medical Disclaimer and Waiver

I, the below named patient, understand, acknowledge, and affirm the following: Ideal Wellness NW, and its subsidiaries are not a medical facility, and it, its consultants and staff cannot, have not, and will not give medical advice, diagnosis or treatment, whatsoever. Nothing discussed, nor any information or products provided to me at IWNW, in any way constitutes medical advice or diagnosis. Any reports, information, documentation, or advice generated or provided to me by IWNW is for my education or knowledge and does not constitute or substitute for physician or health care professional consultation, evaluation, or treatment. *

I acknowledge that it is my responsibility to consult with my physician prior to beginning the IWNW protocol or any weight loss program. I declare that I have been advised by IWNW to seek the advice of my physician regarding any health questions I may have. *

I recognize that IWNW is a weight loss program and any information provided by IWNW is for my knowledge only and does not substitute for professional medical advice. *

I declare that I have not, and will not rely on any information provided to me by IWNW, its consultants, staff or representatives as an alternative to medical advice from my doctor or professional health care provider. *

I confirm that the information that I have provided to my Ideal Wellness NW service provider (IWNW) and that is recorded by me on this 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 identified as NPC or NPA on this form. Furthermore, I understand that I should not be undertaking or otherwise following the Ideal Wellness NW Protocol 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 Wellness NW, ii) remain under the supervision of said medical doctor while I am on the Ideal Wellness NW, and iii) provide documentation confirming the foregoing. 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 following the Ideal Wellness NW Protocol. *

I do hereby release, remise, acquit and forever discharge IWNW, all of IWNW, respective past, present and former parents, subsidiaries, employees, agents, representatives, consultants, attorneys, fiduciaries, servants, officers, directors, general partners, limited partners, members, participants, predecessors, affiliates, corporate divisions, successors, and assigns of, from, and against any and all causes of action, claims demands, damages, costs, losses, injuries, and suits of any kind or nature, known or unknown, existing, claimed to exist or which can be hereinafter ever arise out of result from or in connection with any act, omission, failure to act, breech of conduct suffered to be done or omitted to be done arising directly or indirectly from my participation in the IWNW, LLC. weight loss program.

CLIENT SIGNATURE: *

Date *

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