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.
Where are you located? City, State?
Have you ever been on the ProHealth Diet before?
Approximately how tall are you?
Current Weight (Approximately)
Date of Birth:
How did you hear about us?
Friend or Family
If referred by family or friends, who can we thank?
Do you currently exercise?
Are you willing to temporarily stop/reduce your exercise while on the ProHealth Diet?
How much water do you drink per day?
What kind of water do you drink?
Which best describes your eating habits?
Eats very little during the day and load up at night
Which do you prefer most:
Are you a diabetic?
IF you are a diabetic, which type?
I don't know
Please let us know if you currently HAVE or HAVE HAD any of the following conditions:
High Blood Pressure
Irritable Bowel Syndrome
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.