• Ideal Protein Health Profile

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  • Lifestyle

    About Your Lifestyle
  • Current height
  • Do you currently exercise?*
  • Have you ever been on a diet before?*
  • Marital Status*
  • Do you have a Primary Doctor?*
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  • Do you have a Specialist?*
  • Configurable list*

  • Your Health

    NPA= Needs Prescriber Approval NPC = Needs Prescriber Care

  • Diabetes

    Note: If you are currently on sodium-Glucose Co-Transporter inhibitor medication (SGLT-2), Which include Ebymect,Edistride,Farxiga, Invokana, Jardiance, Synjardy,Vokanamet and Xigduo, YOU CANNOT START OR BE ON IDEAL PROTEIN'S REGUALR PROTOCOL. Please speak to your coach about alternate protocol.
  • Do you have diabetes?*
  • Is your blood sugar monitored?*
  • Who monitors it?*
  • Do you tend to be hypoglycemic?*

  • Cardiovascular Function

  • Have you had any of the following?*

  • Kidney Function

  • Have you had any of the following conditions?*

  • Liver Function

  • Colon Function

  • Do you have any of the following conditions?*

  • Digestive Function

  • Do you have any of the following conditions?*

  • Ovarian/ Breast Function

  • Do you currently have any of the following conditions?*
  • Are you taking oral contraceptive pills?*
  • Are you currently pregnant?*
  • Are you breastfeeding?*

  • Endocrine Function

  • Do you have thyroid problems?*
  • Do you have parathyroid problems?*
  • Do you have adrenal gland problems?*
  • Have you been told that you have metabolic syndrome?*

  • Neurological/Emotional Function

  • Do you have any of the following conditions?*

  • Inflammatory conditions

  • Do you have any of the following conditions?*

  • Cancer

  • Do you have cancer?*
  • Have you ever had cancer?*
  • Is your cancer in remission?

  • General

  • Do you have any other health problems?*

  • Allergies

  • Do you have any food allergies or sensitivities?*

  • Eating Habits

  • Do you eat breakfast?*
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  • Do you have a snack before lunch?*
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  • Do you eat lunch?*
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  • Do you have a snack before dinner?*
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  • Do you eat dinner?
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  • Do you eat a snack before bed?*
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  • Other

  • Are you Vegan?*
  • Are you vegetarian?*
  • Do you smoke?*
  • Do you drink alcohol?*

  • Current Medications

    Please upload your list of medications or fill in below. If you are not on any current medication or supplements, please put N/A in the first tab.
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  • Medications and Supplements*

  • Confirmation of full health status disclosure by the client and agreement to arbritrate disputes

    I confirm that the information that i have provided to my Ideal Protein Protocol service provider (the clinic) and that is recoreded by me on this Ideal Protein Health Profile is true, complete and accurate and that I have not withheld or otherwise omitted, whether in whole or in part, any information concerning my health status. In this respect, I confirm that i have disclosed all past and present i) physical and/or mental health problems or concerns that i have experienced, ii) diagnoses and/or surgeries that I have had, and iii) medications and supplements that were prescribed to me or that I have taken) 

    Without limitations to the foregoing, I specifically confirm that I do not have any of the conditions and that i am not taking any of the medicaitions specifically  identified as NPC or NPA on this form. Furthermore, I understand that I should not be undertaking or otherwise following Ideal Protein Protocol if I have any of the said conditions or if I am currently taking any of the medications unless i) I specifically consult with a medical doctor concerning my suitability to go on the Ideal Protein Protocol,ii) remain under the supervision of said medical doctor while I am on the Ideal Protein Protcol, and iii) provide documentation confirming the foregoing. 

    I understand that if i) I have any of the aforementioned conditions or if I am currently taking any of the aforementioned medications, ii) have not disclosed same to the clinic and iii) nevertheless chose to follow on the Ideal Protein Protcol without specific supervision, such decision will be completely voluntary, and I, for myself and my successors, release and discharge the Clinic as well as Ideal Protein of America Inc., Their parent companies, subsidiaries and affiliates and each of their respective shareholders, directors,employees, agents, representatives, successors and assigns (collectively, the "Releasees") from any and all damages, liabilty, claims and causes of action of any nature whatsoever (including for injury,illness or death) that may result from such voluntary and informed decision of following the Ideal Protein Protocol. 

    I confirm that the Ideal Protein Protocol has been explained to me, that I have had the opportunity to ask questions relating to the Ideal Protein Protocol, that I have been provided with the answers to such questions and that I understand the importance of strictly following the Ideal Protein Protocol as explained to me verbally and in the materials provided to me, both before and during the period I will be following the Ideal Protein Protocol. 

    Without limitations to the foregoing, I confirm that I have been advised that because the Ideal Protien Protocol limits the ingestions of certain foods, it is important that I consume the recommended vitamins and minerals While I am on the Ideal Protein Protocol. 

    I undertake to disclose immediatley to the Clinic any and all changes to my health status, discomfort, symptoms or other health concerns that I may experience while I am following he Ideal Protein Protocol. 

    I specifically agree that all claims against any of the Releasees that I may have or choose to make shall only be submitted to binding arbitration under the rules of the Arbitration Act or similar statute of my state of residence, and I waive any right to pursue any claims or causes of action to any court of law. 

    I agree to receive recurring SMS text messages from my representative (hereafter "coach") and Southern Health and Wellness to the provided mobile number and also agree to the terms and privacy policy. I understand that I may also be contacted by video and voice call by my Southern Health and Wellness coach. Message & Data rates may apply.

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