Home
Contact Us
About Us
>
Disclaimer
Privacy Policy
Professionalism
Certification
Membership
Diabetes Reversal Consultation
*
Indicates required field
Date:
*
DD/MM/YYYY
Client's Name:
*
First
Last
Phone #:
*
Include Area Code
Age:
*
Marital Status:
*
Occupation:
*
How long have you had Type 2 Diabetes?
*
Years
Are you taking any Medication?
*
What have your Blood Sugars been lately?
*
Today and over the past week.
Are you experiencing any Symptoms?
*
Who is your personal Physician?
*
What was your last Hgb A1c level?
*
Include Date.
DM2 Complicatiuons or Other Medical Concerns?
*
How would you describe your Stress Level?
*
1-10. If >6, may include primary source of stress
Do you Smoke?
*
Never
Quit > 6 months ago
Yes
Use tobacco or nicotine in any form.
Do you use Alcohol?
*
Never
Light
Moderate
Heavy
Abstain
Hours of Sleep per day?
*
Per 24 hours.
What Dietary Changes have you made?
*
What Physical Activity Changes have you made?
*
How much has your Weight Changed?
*
BMI:
*
Health Risk Category:
*
Based on complete Body Composition Analysis only.
Medical-Fitness Score:
*
Based on a complete Fitness Analysis only.
Medical-Nutrition Score:
*
Based on a complete Nutrition Analysis only.
What are your Health & Fitness Goals?
*
How committed are you to TLC?
*
1-10. If < 6, may include why not?
Recommendations:
*
Research Enrollment
Blood Chemistry Analysis
Body Composition Analysis
Fitness Analysis
Therapeutic Fitness Training
Nutrition Analysis
Therapeutic Nutrition Training
Lifestyle Medicine Consultation
Therapeutic Lifestyle Training
Medical Integration
Other
Mark all that apply.
If "Other" above, specify below:
*
Diabetes Reversal Plan:
*
Follow-Up:
*
# of Weeks or Months
Photo:
*
Max file size: 20MB
Sports Medicine Technician:
*
Submit
