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Health Intake

                

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



*
								
								Arrhythmia (Abnormal Heart Rhythm)
							

								
								Blood Clot
							

								
								Coronary Artery Disease
							

								
								Heart Valve Problem
							

								
								Heart Valve Replacement
							

								
								History of Heart Attack (Cardiologist Approval)
							

								
								Pulmonary Embolism
							

								
								Stroke or Transient Ischemic Attack (TIA)
							

								
								Child Under Age 17 (Pediatrician Approval)
							

								
								Kidney Disease
							

								
								Kidney Transplant
							

								
								Gastric Ulcer
							

								
								History of Bariatric Surgery
							

								
								Epilepsy
							

								
								Hyperkalemia (High Potassium Level)
							

								
								Hypokalemia (Low Potassium Level)
							

								
								History of Cancer:
							

								
								5 Years or Less
							

								
								More than 5 Years
							

								
								None of These Conditions Apply
							
Do you have a surgery within the next month?*Yes
No
Do you have a vacation scheduled within the next month?*Yes
No

*Please talk to an Ideal Wellness NW Coach prior to your Initial Consultation if you have any questions regarding this Medical Condition Checklist or the accompanying Medical Release form.
CLIENT SIGNATURE*
PRINTED NAME*
Date*
                            
                            Date Format: MM slash DD slash YYYY
                        
                        
 
To Whom It May Concern:

I have reviewed the Ideal Wellness NW Protocol Overview and approve
 
participate in the Ideal Wellness NW Weight Loss Protocol.
PHYSICIAN/PROVIDER SIGNATURE
PRINTED NAME
Date
                            
                            Date Format: MM slash DD slash YYYY
                        
                        
 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 (please use print characters)
First name:*
Last name:*
Address:*
City*
State:*
Zip code:*
Best Phone:*
Email*
                            
                        
Biological Gender:Male
Female
Date of birth:*
Height*
Lowest adult weight (lbs.):*
Highest adult weight (lbs.):*
Profession:*
Referral:
Do you exercise?*Yes
No
How often?*
								
								Daily
							

								
								Weekly
							

								
								Other
							
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: (check one)
What is your marital status?*
								
								Married
							

								
								Single
							

								
								Widow
							

								
								Divorced
							

								
								Other:
							
How many children do you have?*
How old are they?*
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)?*

Please list any physicians (full name) you see and their specialty (refer to medical information for lists of disorders):
Dr
Specialty
PATIENT SINCE DATE
                            
                            Date Format: MM slash DD slash YYYY
                        
                        
Dr
Specialty
PATIENT SINCE DATE
                            
                            Date Format: MM slash DD slash YYYY
                        
                        
Eating Habits
Are you a vegetarian?*
								
								Yes
							

								
								No
							
Are you a Vegan?*
								
								Yes
							

								
								No
							
Do you drink alcohol?*
								
								Yes
							

								
								No
							
If so, what and how often?*
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?*Yes
No
Which Type?*
								
								Type I - Insulin-Dependent (insulin injections only)
							

								
								Type II - Non-insulin-dependent (diabetic pills)
							

								
								Type II - Insulin-dependent (diabetes pills & insulin)
							

								
								N/A
							
Is your blood sugar level monitored?*Yes
No
N/A
If so, how often?*
By Whom:
Myself*
								
								Yes
							

								
								No
							
Physician*
								
								Yes
							

								
								No
							
Do you tend to be hypoglycemic?*
								
								Yes
							

								
								No
							

								
								N/A
							
 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 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?*Yes
No
If so, which type?*
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
							
4. Kidney Function.
Have you had any of the following conditions
Kidney Disease (NPA)*
Kidney Transplant (NPA)*
Kidney Stones (NPA)*
Do you presently have gout?*Yes
No
Since when:*
If yes, what medication has been prescribed?*
If no, have you ever had gout?*
								
								Yes
							

								
								No
							
If yes, when?*
If yes to any of these events, please give dates of events. For multiple events please specify:*
5. Liver Function
Have you ever had any liver conditions?*
								
								Yes
							

								
								No
							
Date
                            
                            Date Format: MM slash DD slash YYYY
                        
                        
If yes, please list:*
Have you ever had a gallstone incident?*
								
								Yes
							

								
								No
							
6. Colon Function
Do you have any of the following conditions:*
								
								Constipation
							

								
								Diverticulitis
							

								
								Crohn’s Disease
							

								
								Irritable Bowel Syndrome
							

								
								Diarrhea
							

								
								Ulcerative Colitis
							

								
								N/A
							
If yes to any of these conditions, please give dates of events:*
*
								
								Please check this box to indicate you have read this section
							
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
							
If so, what type of Bariatric Surgery?*
*
								
								Please check this box to indicate you have read this section
							
8. Ovarian/Breast Function.
Do you currently have any of the following conditions:
*
								
								Amenorrhea
							

								
								Irregular Periods
							

								
								Third ChoiceFibrocystic Breasts
							

								
								Menopause
							

								
								Heavy Periods
							

								
								Painful periods
							

								
								Hysterectomy
							

								
								Uterine Fibroma
							

								
								None of These Conditions Apply
							
Date of last menstrual cycle*
                            
                            Date Format: MM slash DD slash YYYY
                        
                        
Are you taking oral contraceptive pills?*
								
								Yes
							

								
								No
							
Are you pregnant?*
								
								Yes
							

								
								No
							
Are you breast feeding?*
								
								Yes
							

								
								No
							
9. Endocrine Function
Do you have thyroid problems?*
								
								Yes
							

								
								No
							
If so, please specify:*
Do you have parathyroid problems?*
								
								Yes
							

								
								No
							
If so, please specify:*
Do you have adrenal gland problems?*
								
								Yes
							

								
								No
							
If so, please specify:*
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)
							

								
								N/A
							
Are you on Lithium Therapy?*
								
								Yes
							

								
								No
							
Other issues:
*
								
								Please check this box to indicate you have read this section
							
11. Inflammatory Conditions.
Do you have any of the following conditions:
*
								
								Multiple Sclerosis
							

								
								Fibromyalgia
							

								
								Osteoarthritis
							

								
								Lupus
							

								
								Psoriasis
							

								
								Migraines
							

								
								Rheumatoid
							

								
								Chronic Fatigue Syndrome
							

								
								N/A
							
Other autoimmune or inflammatory condition:
*
								
								Please check this box to indicate you have read this section
							
12. Cancer
Do you have cancer?*
								
								Yes
							

								
								No
							
If so, what type and where is it located?*
Have you ever had cancer?*
								
								Yes
							

								
								No
							
If so, what type and where is it located?*
Is your cancer in remission?*
								
								Yes
							

								
								No
							

								
								N/A
							
If so, how long have you been in remission?*
                                            
                                            MM
                                        

                                            
                                            DD
                                        

                                            
                                            YYYY
                                       
                                   
13. General
Do you have any other health problems?*
								
								Yes
							

								
								No
							
If so, please specify:*
14. Allergies
Do you have any food allergies or sensitivities?*
								
								Yes
							

								
								No
							
If so, please specify:*
15. Medications & Supplements.
Please list all prescriptions medications and supplements you are currently taking.
*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.
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?*
								
								Yes
							

								
								No
							
Are you open to changing the food your kids eat too? (i.e. more vegetables, healthier options)*
								
								Yes
							

								
								No
							
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?*
								
								Yes
							

								
								No
							
If yes, briefly describe:*
Medical Disclaimer and Waiver
I*

, 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 constitue or substitute for physician or health care professional consultation, evaluation, or treatment.
I*

 (initials), 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*

(initials), 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*

(initials), 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. 


By signing this Disclaimer and Waiver 
I*

 (print name), 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*
                            
                            Date Format: MM slash DD slash YYYY
                        
                        
COACH SIGNATURE:
Date
                            
                            Date Format: MM slash DD slash YYYY
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Request an Appointment

If you’re a current patient, please do not use this as a form of communication.
* All questions require a Yes, No or N/A response.

1. Overall (please use print characters)

Eating Habits

2. Diabetes.

3. Cardiovascular Function.

Have you had any of the following conditions:

4. Kidney Function.

Have you had any of the following conditions

5. Liver Function

6. Colon Function

7. Digestive Function.

Do you have any of the following conditions:

8. Ovarian/Breast Function.

Do you currently have any of the following conditions:

9. Endocrine Function

10. Neurological/Emotional Function.

Do you have any of the following conditions:

11. Inflammatory Conditions.

Do you have any of the following conditions:

12. Cancer

13. General

14. Allergies

15. Medications & Supplements.

Please list all prescriptions medications and supplements you are currently taking.

16. Goals & Habits

Medical Disclaimer and Waiver

Blank file

Request an Appointment

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