Contact Us: 208-939-2502
Dietary consultation involves a health profile whose purpose 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 profile.
General
Click for instructions
Last Name
First Name
Address 1
Apt/Unit: #
City
State
Zip
Phone
Cell
Please enter your email
Password
Please re-enter password below:
Date of Birth
Profession
Whom may we thank for referring you?
Weight (lbs)
Height
Lowest adult weight
Age of lowest adult weight
Max adult weight
Age of max adult weight
What is your ideal weight?
Do you exercise?
Yes
No
If yes, what kind?
How often do you exercise?
Have you been on a diet before?
Yes
No
If yes, please specify which diet and why you think it didn't work for you (e.g. too rigid, too much cooking involved, etc.):
On a scale of 1 to 10, indicate what level of importance you give to losing weight via Ideal Protein's medically supervised weight loss method (10 being the most important):
Family Life
Click for instructions
What is your marital status?
Married
Single
Divorced
Widowed
Do you have children?
Yes
No
Number of children:
Ages of children:
Medical Information
Click for instructions
Who is your family MD?
Phone:
Please list any other physicians you see and their specialty:
Diabetes
Click for instructions
Do you have diabetes? (If no, skip to next section)
Yes
No
If so, are you under the care of a physician?
Yes
No
If so, which type?
Type I - insulin dependent (insulin injections only)
Type II - non-insulin dependent (diabetic pills)
Type II - insulin dependent (diabetic pills and insulin)
Is your blood sugar level monitored?
Yes
No
If so, by whom?
Myself
Physician
Other
If other, please specify:
Are you taking any medication?
Yes
No
If so, please list:
Do you tend to be hypoglycemic (low blood sugar)?
Yes
No
Cardiovascular Health
Click for instructions
Have you had a cardiovascular event? (If no, skip to next section)
Yes
No
If so, please specify:
How long ago?
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
Do you have a history of arrhythmia?
Yes
No
Hypertension
Click for instructions
Do you have high blood pressure? (If no, skip to next section)
Yes
No
If so, do you have your blood pressure checked?
Yes
No
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
Kidney Health
Click for instructions
Have you been diagnosed with kidney disease? (If no, skip to next section)
Yes
No
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
Have you ever had Gout?
Yes
No
Liver Health
Click for instructions
Do you have liver problems? (If no, skip to next section)
Yes
No
If so, please specify:
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
Colon Health
Click for instructions
Do you have:
   All
Irritable Bowl
Colitis
Constipation
Crohn's Disease
Diarrhea
Diverticulosis
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
Stomach/Digestive Health
Click for instructions
Do you have:
   All
Acid Reflux
Celiac Disease
Gastric Ulcer
Heartburn
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
Ovarian/Breast Health
Click for instructions
Check off the situations that apply to you currently:
   All
Amenorrhea
Cancer (uterus
breast)
Fibrocystic Breasts
Heavy Periods
Hysterectomy
Irregular Periods
Menopause
Painful Periods
Uterine Fibroma
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
Please indicate the date of your last menstrual cycle:
Thyroid Function
Click for instructions
Do you have thyroid problems? (If no, skip to next section)
Yes
No
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
Emotional Evaluation
Click for instructions
Do any of the following apply to you? (If no, skip to next section)
   All
Anorexia (or history of)
Anxiety
Bulimia (or history of)
Depression
Panic Attacks
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
Inflammatory Conditions
Click for instructions
Do any of the following apply to you? (If no, skip to the next section)
   All
Chronic Fatigue Syndrome
Fibromyalgia
Lupus
Migraines
Osteoarthritis
Psoriasis
Rheumatoid Arthritis
Other Autoimmune or Inflammatory Condition
If other, please specify:
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
General
Click for instructions
Do you have cancer?
Yes
No
Are you in cancer remission?
Yes
No
If so, please specify and indicate for how long:
If so, are you under the care of a physician?
Yes
No
Are you taking any medication?
Yes
No
If so, please list:
Are you generally fatigued or have low energy?
Yes
No
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Do you get cold easily?
Yes
No
Do you have cold hands/feet?
Yes
No
Do you have other health problems?
Yes
No
If so, please specify:
If so, are you under the care of a physician?
Yes
No
Are you taking any other medications not listed above?
Yes
No
If yes, please list:
Are you currently taking Vitamins, Herbs, or Supplements?
Yes
No
If so, please list the name of each and reason for taking them:
Allergies
Click for instructions
Do you have any food allergies?
Yes
No
If so, please list:
Do you have any medication allergies?
Yes
No
If so, please list:
Eating Habits
Click for instructions
(please be as honest as possible so that we may better help you)
Do you have breakfast every morning?
Yes
Sometimes
Never
Approximate time:
Examples:
Do you have a snack before lunch?
Yes
Sometimes
Never
Approximate time:
Examples:
Do you have lunch every day?
Yes
Sometimes
Never
Approximate time:
Examples:
Do you have a snack before dinner?
Yes
Sometimes
Never
Approximate time:
Examples:
Do you have dinner every day?
Yes
Sometimes
Never
Approximate time:
Examples:
Do you have a snack at night?
Yes
Sometimes
Never
Approximate time:
Examples:
Do you prefer:
   All
Sweet foods
Salty foods
Fatty foods
Are you a vegetarian?
Yes
No
How many glasses of water do you drink per day?
How many cups of coffee do you drink per day?
Do you smoke?
Yes
No
If yes, how many packs per day?
For how many years?
Do you drink alcohol?
Yes
No
If yes, how much and how often?
CASH Scale: Compulsions or Cravings/Appetite/Satiety/Hunger
Click for instructions
Score each item on a 0-10 numbering scale. Each feeling represents a different part of the brain and different neurotransmitters.
Compulsions/Cravings: Feeling or urge to eat when not hungry. You are full. There is no food in sight. You get an urge to eat which cannot be repressed.
Appetite: Feeling of hunger stimulated by sight, sounds, smells, or social cues. You recently ate and feel full. You walk into a room. There is food everywhere. It looks and smells good. Everyone is having fun. You:
Satiety: A feeling of fullness acquired during eating. When you eat, you usually:
Hunger: That feeling of a pain or ache in your stomach when really empty. This is a true pain or discomfort.
Consent
Click for instructions
You must take vitamins and minerals while you are on the Ideal Spine Health Center Weight Loss Program. If you stop taking them, you may experience undesirable side effects. (Please initial below in acknowledgement)
If you are taking medications, are you interested in getting off of any or all of your prescription medications?
Yes
No
If you have health problems not indicated on this health profile, please consult your physician.
Client Signature
The signatory client hereby recognizes the veracity of the information provided herein that he/she has made an informed decision to go on the Ideal Spine Health Center Weight Loss Program.
Email
Reminder Email
Welcome Email
 
 
 

X
Find a Physician
Please fill out the form below to find a physician.
Thank you for your inquiry!

You should hear from us within one business day.
TeamViewer for PC TeamViewer for MAC Click Here to Start Download Java TeamViewer for PC TeamViewer for MAC Click Here to Start Download Java
head commonz......................................0.0273437500
head 103..........................................0.0039062500
nyroModal include.................................0.0000000000
head end..........................................0.0000000000
Top_nav - contact drop-down tab...................0.0000000000
Top_nav - Main Code...............................0.1015625000
Top_nav - Past components check...................0.0039062500
Top_nav - Past https - now rendering top nav......0.0039062500
Top_nav - Render the page.........................0.0468750000
Top_nav end.......................................1.7070310000
footer()..........................................0.0000000000
REGISTER2.ASP TOTAL...............................2.2187500000