Who is your primary care physician (family doctor)? Please list any physicians you see and their specialty (refer to medical information for list of disorders): Dr. Specialty: Patient since: Last visit: (MM/YY) Dr. Specialty: Patient since: Last visit: (MM/YY) Dr. Specialty: Patient since: Last visit: (MM/YY) Dr. Specialty: Patient since: Last visit: (MM/YY) 2. Diabetes N/A Do you have diabetes? Yes No If no, please skip to next section. Type I Insulin-dependent (insulin injections only) Which type? – Type II Non-insulin-dependent (diabetic pills) – Type II Insulin-dependent (diabetic pills and insulin) – Is your blood sugar level monitored? Yes No If so, how often? If so, by whom? Myself Physician Other please specify: – Do you tend to be hypoglycemic? Yes No NOTE: If you are currently on Sodium-Glucose Co-Transporter inhibitor medication (SGLT-2), which include Ebymect, Edistride, Forxiga, Invokana, Jardiance, Synjardy, Vokanamet and Xigduo, YOU CANNOT START Please speak to your coach about our Alternative OR BE ON IDEAL PROTEIN’S REGULAR PROTOCOL. Protocol. 3. Cardiovascular Function N/A Have you had any of the following conditions? Arrhythmia (NPA) Hyperkalemia (High potassium) (NPA) Blood Clot (NPA) Hypokalemia (Low potassium) (NPA) Coronary Artery Disease (NPA) Hypertension (High blood pressure) (NPA) Heart attack (NPC) Pulmonary Embolism (NPA) Heart Valve Problem (NPA) Stroke or Transient Ischemic Attack (NPA) Heart Valve Replacement (porcine/ mechanical) (NPA) Congestive Heart Failure (NPC) Hyperlipidemia Please select one (if applicable): (High cholesterol/triglycerides) History of Congestive Heart Failure Current Congestive Heart Failure (NPC) 3. Cardiovascular Function (cont.) N/A Have you ever had any type of heart surgery? Yes No If so, which type? Other conditions:
Who is your primary care physician (family doctor)? Please list any physicians you see and their specialty (refer to medical information for list of disorders): Dr. Specialty: Patient since: (MM/YY) Last visit: Dr. Specialty: Patient since: (MM/YY) Last visit: Dr. Specialty: Patient since: (MM/YY) Last visit: Dr. Specialty: Patient since: (MM/YY) Last visit: 2. Diabetes N/A Do you have diabetes? Yes No If no, please skip to next section. Which type? Type I – Insulin-dependent (insulin injections only) Type II – Non-insulin-dependent (diabetic pills) Type II – Insulin-dependent (diabetic pills and insulin) Is your blood sugar level monitored? Yes No If so, how often? If so, by whom? Myself Physician Other – please specify: Do you tend to be hypoglycemic? Yes No NOTE: If you are currently on Sodium-Glucose Co-Transporter inhibitor medication (SGLT-2), which include Ebymect, Edistride, Forxiga, Invokana, Jardiance, Synjardy, Vokanamet and Xigduo, YOU CANNOT START OR BE ON IDEAL PROTEIN’S REGULAR PROTOCOL. Please speak to your coach about our Alternative Protocol. 3. Cardiovascular Function N/A Have you had any of the following conditions? Arrhythmia (NPA) Hyperkalemia (High potassium) (NPA) Blood Clot (NPA) Hypokalemia (Low potassium) (NPA) Coronary Artery Disease (NPA) Hypertension (High blood pressure) (NPA) Heart attack (NPC) Pulmonary Embolism (NPA) Heart Valve Problem (NPA) Stroke or Transient Ischemic Attack (NPA) Heart Valve Replacement (porcine/ mechanical) (NPA) Congestive Heart Failure (NPC) Hyperlipidemia Please select one (if applicable): (High cholesterol/triglycerides) History of Congestive Heart Failure Current Congestive Heart Failure (NPC) 3. Cardiovascular Function (cont.) N/A Have you ever had any type of heart surgery? Yes No If so, which type? Other conditions:
4-Writable-US_Health-Profile_2017-09-18.docx