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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 I I I I I I I I I I 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 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 High cholesterol Heart problems Prickling Nose bleeding Chilliness Numbness High triglycerides Low blood pressure 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 Pain on liver side Pale stools Headaches Nausea, eructations Heartburns Dark stools Gas and/or flatulence Diverticulitis Gall stones Vomiting Constipation Dizziness Tiredness Ulcer Hemorroides Bad breath Cramps (abdomen) Difficult digestion TEGUMENTARY SYSTEM (HAIR-NAILS-SKIN) Irritation, eczema, psoriasis Brittle and dull hair Oily skin Dry skin Brittle nails 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 : Phobias Worn out Excitability Weakness Stress (excess) Depression Trembling Sciatic /12 BONE SYSTEM IMMUNE SYSTEM /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