Diabetes/Hypoglycemic
Do you have Diabetes? (*)
Yes
No
If so, which type: (*)
Type I
Type II
Insulin Required
Are you under the care of a physician? (*)
Yes
No
If so, Name of Physician: (*)
Phone: (*)
Are you Hypoglycemic? (*)
Yes
No
Are you taking any Diabetes medication? (*)
Yes
No
If so, please list the medication, dosage and how many times per day: (*)
Cardiovascular
Have you ever had a cardiovascular event? (*)
Yes
No
If so, please check any of the below that you have experienced: (*)
Arrhythmia
Blood Clots
Congestive Heart Failure
Heart Attack
Heart Surgery
Heart Valve Problem
High Cholesterol
Hypertension (High Blood Pressure)
Stroke or TIA
If you have had any of the events above, please give more details and dates of each event: (*)
Are you taking medication for any of the above? (*)
Yes
No
If so, please list the medication, dosage and how many times per day: (*)
Liver & Kidney Functions
Do you have any kidney problems? (*)
Yes
No
Do you have any liver problems / high liver enzyme levels? (*)
Yes
No
If yes, please explain: (*)
Have you had any of the following: (*)
Kidney Disease
Kidney Stones
Kidney Transplant
Fatty Liver
Cirrhosis of the Liver
Renal Failure
NA
If you have had any of the events above, please give more details and dates of each event: (*)
Are you taking medication for any of the above? (*)
Yes
No
If so, please list the medication, dosage and how many times per day: (*)
Colon Function
Do you have any of the following: (*)
Colitis
Constipation
Crohn's Disease
Diarrhea
Diverticulitis
Irritable Bowel
NA
If so, please give more details and date of each event: (*)
Do you take medications for any of the above? (*)
Yes
No
If so, please list the medication, dosage and how many times per day: (*)
Digestive Functions
Do you have any of the following: (*)
Acid Reflux
Gastric Ulcer
Heartburn
Bariatric Surgery
Lap Band Surgery
Other
NA
If so, please list details and dates of each: (*)
Are you taking medication for any of the above? (*)
Yes
No
If so, please list the medication, dosage and how many times per day: (*)
Inflammatory Conditions
Do you have any of the following: (*)
Arthritis
Chronic Fatigue
Gout
Fibromyalgia
Lupus
Migraines
Psoriasis
Other
NA
If you have had any of the events above, please give more details and dates of each event: (*)
Are you taking medication for any of the above? (*)
Yes
No
If so, please list the medication, dosage and how many times per day: (*)
Cancer History
Do you have or have you had cancer? (*)
Yes
No
If yes, are you in remission? (*)
Yes
No
If you have or have had cancer, please give details and dates below: (*)
Are you taking any medications for treatment of cancer? (*)
Yes
No
If so, please list the medication, dosage and how many times per day: (*)
Other Conditions
Do you have any of the following: (*)
Alzheimer's
Parkinson's
Multiple Sclerosis
Hypothyroidism
Hyperthyroidism
Seizures
Other
NA
If so, please give more details and date of each event: (*)
Are you taking medication for any of the above? (*)
Yes
No
If so, please list the medication, dosage and how many times per day: (*)
For Women Only
Do you have any of the following: (*)
Fibrocystic Disease
Hysterectomy
Irregular Periods
Menopause
Polycystic Ovary Syndrome (PCOS)
Uterine Fibroids
NA
If you have had any of the events above, please give more details and dates of each event: (*)
Are you taking medication for any of the above? (*)
Yes
No
If so, please list the medication, dosage and how many times per day: (*)
Start date of your last menstrual cycle:
Month
01
02
03
04
05
06
07
08
09
10
11
12
/
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Year
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Are you Pregnant? (*)
Yes
No
Are you breastfeeding? (*)
Yes
No
Please note: Rapid weight loss may cause an increase in the level of estrogen in the bloodstream. This in turn may possibly affect menstrual cycle regularity, change PMS symptoms, and/or increase fertility. Please contact your OB-GYN if you have any concerns or questions. It is recommended when on the program to use an alternative birth control method if on oral contraceptives.
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Thank you for choosing ITG for your nutritional and weight loss needs. If you are ready to get started as a member of our ITG weight loss plan, join the many other successful members on their weight loss journeys and receive the expert advice from our health coaches, then please fill out the Health Status Intake Form below to get started! Once you submit your health profile, one of our health coaches will contact you by the next business day to advise you on the products to purchase in order to achieve your weight loss goals and to confirm your unique username and password to our members only tools section. Please note: If there is a clinic in your area, we may refer you to that local clinic for personalized one-on-one coaching. If you are already working with an ITG Clinic, please continue to work with that clinic for one-on-one coaching.
