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ProHealth Diet... Health Profile
This Health Profile must be filled out and reviewed by the supervising doctor BEFORE beginning the ProHealth Diet. Please be as accurate as possible.
Today's Date
Name
First
Last
Where are you located? City, State?
Have you ever been on the ProHealth Diet before?
Yes
No
Approximately how tall are you?
Current Weight (Approximately)
Goal Weight
Date of Birth:
Age
Phone
###
-
###
-
####
Email
How did you hear about us?
Please select
Friend or Family
Facebook
Radio
Internet Search
Other
If referred by family or friends, who can we thank?
Do you currently exercise?
Yes
No
Sometimes
Are you willing to temporarily stop/reduce your exercise while on the ProHealth Diet?
Yes
No
Maybe
How much water do you drink per day?
What kind of water do you drink?
Which best describes your eating habits?
Please select
Eats frequently
Skips meals
Eats very little during the day and load up at night
Which do you prefer most:
Please select
Sweet foods
Salty foods
Are you a diabetic?
IF you are a diabetic, which type?
Please select
Pre-Diabetic
Type I
Type II
I don't know
Please let us know if you currently HAVE or HAVE HAD any of the following conditions:
Have Had
Currently Have
Acid Reflux
Anxiety
Arthritis
Cancer
Cardiovascular Event
Constipation
Depression
Diarrhea
Fibromylagia
High Blood Pressure
High Cholesterol
Irritable Bowel Syndrome
Kidney Issues
Liver Issues
Migraines
Thyroid Issues
OTHER
IF yes to any of the above, please explain:
Please list any VITAMINS or SUPPLEMENTS you currently take:
Please list any and all MEDICATIONS you are currently taking AND what they are for.
(For example: Metformin for Diabetes, etc.)
Please tell us a little about yourself (interests, hobbies, etc.) so we can match you with the BEST- FOR-YOU coach!
On a scale of 1-10, how ready are you to lose weight?
10! I am so ready! I am ready to get my HEALTH & HAPPINESS back to where they should be!
5... I am only kind-of ready. Honestly, I'm not sure I want to do this.
1-2... I don't want to do this, but my family , friends, and doctor think I need to.
The BUDDY SYSTEM is powerful! Do you have any family, friends, or neighbors you think may be interested in this journey with you? We do not need names but do you have POTENTIAL weight loss partners in mind? If so, your coach will explain the referral system to you.
YES
NO
