Download BILAN DE SANTÉ

HEALTH STATUS REPORT
personal and confidential
To maintain good health one must pay attention to the body’s imbalances.
The best treatment: PREVENTION !!
Contact #:
Date:
Name:
First name:
Tel :
Referred by:
Occupation:
Date of birth:
Address :
Height:
Weight:
E-MAIL :
Do you authorise Ideal Body Clinic to email you our specials and promotions?
Y
N
Client’s signature :
Are you affected on a regular basis:
By diarrhea ?
By high blood pressure ?
Yes 
Yes 
No 
No 
Have you ever been subjected to any Yes 
surgery?
If yes, specify:
No 
Do you regularly intake prescription
or off the shelf medication?
If yes, specify:
No 
Do you intake natural supplements? Yes 
If yes, specify:
No 
Antecedent health trouble :
Yes 
Genetic predisposition maternal/paternal relatives:
Yes 
Are you pregnant?
If yes, how many weeks ?
Do you suffer from particurlar problems ?
No 
LIFESTYLE HABITS ANALYSIS AND EVALUATION
(√ check when present)
NUTRITION
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I
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I
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I
I
I
drink more than 2 coffees, teas, soft drinks per day.
drink alcohol every day.
eat few fruits and vegetables.
eat red meat more than 3 times/week
eat a lot of fried food.
eat a lot of refined food.
have frequently weight problems.
frequently eat “fast food”.
over eat.
 I eat salted.
eat very quickly.
 I don’t eat breakfast.
am often on a diet.
 A lot of desserts.
eat little fibers.
 I eat very sugary.
often skip meals.
 My diet is not diversified.
/18
HYDRATATION
SLEEP
 I sleep less than 8 hours per day.
 I often go to bed after midnight.
 My sleep is disturbed.
 Shift time work.
/4
STRESS
 I am a stressed person.
 At work, I am stressed.
 I am always tired and weak.
 I have few spare time activities.
/4
ENVIRONMENT
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I smoke cigarette, cigar, pipe or others.
I spend less than one hour per day outside.
At work, air exchange is not adequate.
I live in a polluted environment.
/4
 I drink less than 8 glasses of water per day.
I drink water
:  From tap
 From source
 Bottled
 Others
/1
Add check marks to obtain final score
0 to 6—GREEN LIGHT
/33
Keep your good habits, you have excellent lifestyle habits.
7 to 12—YELLOW LIGHT
PHYSICAL ACTIVITY
You have to correct several lifestyle habits to be in good health.
 I exercise less than 3 hours per week.
 I have a sedentary work.
13 and more—RED LIGHT
/2
You have to correct a lot of your lifestyle habits to be in good
health.
SYSTEMIC EVALUATION
(√ check when present)
CIRCULATORY SYSTEM
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High cholesterol
Heart problems
Prickling
Nose bleeding
Chilliness
Numbness
High triglycerides
Low blood pressure
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RESPIRATORY SYSTEM
Œdema
Palpitations
High blood pressure
Slow cicatrisation
Hot flashes, sweat
Varix, varicositis
Ecchymosis (blue)
 Short breath
 Asthma
 Heavy respiration
 Bronchitis, rhinitis
 Nicotinism
 Respiratory problems
/6
/15
Your blood pressure: _________ Your blood type :_______
Your cholesterol rate : HDL ______ LDL _____ Total _____
URO-GENITAL SYSTEM
 Frequent urinary infections
 Insufficient urine
 Pain
 Strong smell
 Colored urine
 Pale urine
 Heavy perspiration
 Blood in urine
 Renal stones
 Œdema
 Fibrome
 Gout
DIGESTIVE SYSTEM
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Pain on liver side
Pale stools
Headaches
Nausea, eructations
Heartburns
Dark stools
Gas and/or flatulence
Diverticulitis
Gall stones
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Vomiting
Constipation
Dizziness
Tiredness
Ulcer
Hemorroides
Bad breath
Cramps (abdomen)
Difficult digestion
TEGUMENTARY SYSTEM (HAIR-NAILS-SKIN)
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Irritation, eczema, psoriasis
Brittle and dull hair
Oily skin
 Dry skin
Brittle nails
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Hair lost
Dandruff
Cellulitis
Acne
/9
/18
ENDOCRINAL SYSTEM
 Thyroid imbalance
 Hypoglycaemia
 Obesity
 Difficult growth
 Difficult puberty
Woman
 Frequent vaginal infections
 Difficult monthly periods
 Menopause problems
/10
NERVOUS SYSTEM
 Diabetes
 Acne
Man
 Itching
 Painful urination
 Prostate troubles
/4
MUSCULAR SYSTEM
 Muscular pains
 Muscular cramps
 Bursitis, tendinitis
Insomnia
Nightmares
Irritability
Memory problems
 Bursitis, tendinitis
 Arthritis
/10
Repetitive infections (cold, flu, fungus, etc.)
Frequent use of antibiotics.
Have you suffered mononucleosis?
Allergies :  food,  respiratory,  others
specify :
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Phobias
Worn out
Excitability
Weakness
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Stress (excess)
Depression
Trembling
Sciatic
/12
BONE SYSTEM
IMMUNE SYSTEM
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/12
 Muscular stiffness
 Frequent sprains
 Torticollis
/6
 Arthrosis
 Bone fragility
Skeleton :  Small
 Average
 Osteoporosis
 Fracture
/6
 Large
 Systemic evaluation points out the systems that need
to be helped.
 Laboratories Vachon’s Detoxification Treatment
will eliminate toxins accumulated in the organism as
these waste substances are harmful to body
functions. After treatment, the regeneration is
obtained by adopting a complete and natural diet and
by adding high quality supplements.
 Having recovered health, it is imperative to maintain it
with good lifestyle habits (healthy diet, relaxation,
physical activities, etc.), and high quality food
supplements
Ideal Body Clinic
5725 Monkland, Montreal, Qc H4A 1E7
Tel. (514) 998 0998 / Fax. (514) 658 8948
Web site: www.911slim.com