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  • ZENITH HEALTH INSTITUTE

  • MEDICAL HISTORY FORM

    The following HIPAA Compliant questionnaire is for people who have already scheduled an online coaching session. It is a comprehensive look at your current health and dietary status. Please answer it to the best of your ability as it will enable the Doctor to come up with an individualized plan that will work best for you. The form should take about 15 minutes to complete. Thank you!
  • DATE*
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  • Gender*
  • What are the main reasons why you are requesting this consult? Tick all that apply*

  • Next: Medical History

  • Medical History

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  • Are you under a Doctors care right now?
  • Is your Medical Doctor aware that you are starting a coaching program with us?
  • Do you ever get any of the following? Tick all that apply:

  • Are there any of the following medical conditions in any of your immediate family members? Please tick all that apply.

  • Next: Womens Health History ...

  • Womens Health History

  • Do you use oral contraceptive pills or hormone replacement therapy?
  • Approximate date of last menstrual period
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  • Do you ever get any of the following? Tick all that apply

  • Next: Weight History . . .

  • Weight History

    (Skip these questions if you are not interested in weight loss)
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  • Is your spouse/ fiancee/ partner overweight?

  • Next: Current Diet

  • Current Diet

    Outline what you eat in an average day

  • BREAKFAST

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  • Who do you eat it with?
  • Where do you eat it?

  • LUNCH

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  • Who do you eat it with?
  • Where do you eat it?

  • DINNER

  •  :
  • Who do you eat it with?
  • Where do you eat it?

  • SNACK

  •  :
  • Who do you eat it with?
  • Where do you eat it?
  • Do you drink coffee?
  • Do you drink soft drinks?
  • Do you drink alcohol?
  • In order to control weight do you ever vomit?
  • Do you ever wake up hungry at night?
  • Do you ever continue to eat even after you are full?

  • Next: Lifestyle

  • Lifestyle

  • Rows
  • Do you exercise?*
  • What activities do you enjoy doing in your spare time? Tick all that apply

  • Coaching Consent Form

  • I hereby authorize Dr. Hevi and any employee working under his direction to provide wellness and/or weight loss coaching for me. I understand that I am seeing Dr. Hevi strictly in the capacity of a coach and I am NOT establishing a Patient-Doctor relationship…my regular Doctor will remain the final authority with regards to my health and I will inform my Doctor before making any changes that might impact my health.

    My program will consist of dietary advice, exercise advice, counseling, behavior modification techniques, and may involve the recommendation of natural supplements (which I will tell my Doctor about). The natural supplements that may be used in this program have been proven to be safe, however I acknowledge the rare possibility that an adverse reaction could occur. I understand that I am only to use the specific supplements prescribed by Dr. Hevi-the use of any other brands could result in adverse reactions or treatment failure and I will hold myself solely to blame if such were to happen.

    I understand that any treatment may involve risks as well as the proposed benefits. I also understand that there are health risks associated with remaining chronically ill, out of balance, overweight, or obese. Risks of this program may include but are not limited to constipation, sleeplessness, headaches, gastrointestinal disturbances, weakness, tiredness, psychological ailments, low blood pressure, low blood sugar (in diabetics). These and other possible risks could, on occasion, be serious or even fatal.  Risks associated with remaining chronically ill/ overweight are tendencies to high blood pressure, diabetes, heart attack and heart disease, strokes, arthritis of the joints, cancer, sleep apnea, dementia, depression, shortened life span, sudden death etc.

    I understand that much of the success of the program will depend on my own efforts and that there are no guarantees or assurances that the program will be successful. I also understand that the conditions that will be addressed may be chronic and life-long and may require supplements, changes in eating habits and permanent changes in behavior to be treated successfully.

    I am currently not pregnant, and I am aware that I need to inform Dr. Hevi immediately if I do get pregnant on the program, or if I decide to start trying for a baby.

    I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been given all the time I need to read and understand this form.

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