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Patient
ID Number___________
(subjects ~initials)
Date
of Birth:________________
Male/Female_________________
Today’s
Date:________________
Reviewer’s
lnitials____________
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Medical
and Lifestyle Information:
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Date
Height (cm) Weight (kg)
Blood Pressure (mmHgj
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Initial
Visit:
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Final
Visit:
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Do
Do you have the following medical conditions (circle Yes or No)?\
1.
Heart disease
Yes
No
2. Diabetes
Yes
No
If
you answered “Yes” to Question 2, please circle one of the following:
Type 1 Type 2
3.
High blood pressure (hypertension)
Yes
No
4.
Renal or kidney disease/failure
Yes
No
5.
Gastrointestinal condition such as Crohn’s disease, irritable bowel
syndrome, ulcer, or history of bowel
surgery
Yes
No
6. History of blood clotting disorder
Yes
No
7. Liver disease such as cirrhosis
Yes
No
8. Condition that requires the use of steroid medication
Yes
No
9. Thyroid disease or thyroid problem requiring treatment
Yes
No
10. Do you take any type of doctor-prescribed medication?
Yes
No
If
you answered YES, please provide details of the medication in the chart
below
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Date
Started
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Name
of Product (type of product)
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Reason
for Use
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11. Do you currently smoke?
Yes No
12. Do you exercise more than ten (10) hours a week or play sports
regularly?
Yes No
13. Are you currently on a weight-loss program or diet?
Yes No
14. At the Final Visit please provide feedback about this Program:
(Complete Feedback on other side)
Return
this form at the conclusion of the program.
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