Symptoms and Areas of Concern (check all that apply)
Acne Circulation Hiatal Hernia Pneumonia
ADD/ADHD Cold - Common Hives Polyps
Adrenal Glands Cold - Temperature Hormones Pregnancy
Allergies Colic Hyperactive Prostate
Alzheimer’s Disease Colon Hypertension Psoriasis
Anemia Constipation Hyperthyroidism Rash
Anger Cough Hypoglycemia Reproductive
Anxiety Cravings Impotence Respiratory
Appetite Dandruff Incontinence Rheumatism
Arteriosclerosis Depression Indigestion Ring worm
Arthritis Diabetes Insomnia Seizures
Asthma Diarrhea Joint Pain Shingles
Back Pain Digestion Kidney Issues Sinus
Bad Breath Dizzy Spells Kidney Stones Skin Issues
Bed Wetting Ear Infection Laryngitis Snoring
Bell’s Palsy Ear Ringing Leprosy Sore Throat
Bites Edema Leukemia Stomach
Bladder Emphysema Liver Stress
Blood Pressure - High Epilepsy Lung Issues Stroke
Blood Pressure - Low Eyesight Lupus Sty
Boils Fatigue Lymph Glands Teething
Bones Fever Menopause Tennis Elbow
Breathing Flu Menstrual Cramps Tonsillitis
Bronchitis Gallstones Migraines Tumors
Bruises Gangrene Mononucleosis Ulcers
Burns Gas Mucous Urinary Infections
Cancer Gout Nails Varicose Veins
Candida Gums Nausea Vertigo
Canker Sores Hair Issues Nervousness Weight - Overweight
Carpal Tunnel Headache Nose Bleeds Weight - Underweight
Cataracts Heart Issues Parasites Yeast Infections
Chest Congestion Heartburn Parkinson’s Disease OTHER:
Chest Pain Hemorrhoids Perspiration
Health History 2
1 ©2020 SHAPE ReClaimed
Health History
Name: __________________________________________________ Date: _________________ Birthdate: ____________________________ Age: __________ Sex: Male Female
Home Address: _____________________________________________________________________________________ City: __________________________________________________________ State: ___________ Zip: ______________ Home Phone: ______________________________________ Cell Phone: ______________________________________ Email: _____________________________________________________________________________________________ Occupation: ________________________________ Do you primarily: Sit Stand Perform repetitive tasks Are you: Single Partnered Married Divorced Widowed
Names and ages of children: ___________________________________________________________________________ How did you hear about the SHAPE Program? _____________________________________________________________ What health benefits do you want to achieve with the SHAPE Program?
Improved eating habits Improved well-being Decreased inflammation Weight loss
Increased energy Improved sleep Increased stamina Other _____________________________
Physical Health
Height: __________________________________________ Weight: __________________________________________ Are there any areas of your body that are not functioning optimally? Yes No
If yes, explain: _______________________________________________________________________________ On average, how many hours do you sleep per night? <5 6 7 8 9 10
Do you wake up feeling refreshed? Always Sometimes Rarely Never Have you ever been hospitalized or had surgery? Yes No
If yes, why and when? _________________________________________________________________________ Have you been diagnosed with any clinical condition or disease? Yes No
If yes, what? _________________________________________________________________________________ Have you ever been in a motor vehicle accident? Yes No
If yes, what kind and when? ____________________________________________________________________ Were you evaluated and treated after the accident? Yes No
Have you had any non-vehicle accidents or falls? Yes No
If yes, explain: _______________________________________________________________________________ Have you had any imaging performed in the last year? X-ray MRI US PET No
Have you had blood work performed in the last year? Yes No Were your test results in medically normal ranges? Yes No
Food Health
Please list the foods you commonly eat for:
Breakfast: ___________________________________________________________________________________ Lunch: ______________________________________________________________________________________ Dinner: _____________________________________________________________________________________ Snacks: _____________________________________________________________________________________ How many cups of vegetables do you eat per day? 0 1 2 3 4 5 6 7+
What foods do you crave? ____________________________________________________________________________ What are some specific goals you have regarding the SHAPE Program? ________________________________________ __________________________________________________________________________________________________
Chemical Health
Do you choose to get annual flu shots? Yes No Have you used antibiotics in the last year? Yes No
How many cups of water do you drink per day? 0 1-3 4-6 7-9 10+
How many cups of coffee/energy drinks do you drink per day? 0 1-3 4-6 7-9 10+ How many glasses of juice/soda/sports drinks do you drink per day? 0 1-3 4-6 7-9 10+ Do you eat wheat products (bread/pasta/crackers/baked goods) ? Yes No
If yes, how many servings per day? _______________________________________________________________ Do you eat refined sugar? Yes No
If yes, how many servings per day? _______________________________________________________________ Do you ingest artificial sweeteners (Splenda, Aspartame, Equal, diet drinks, gum) ? Yes No
Do you have any food/drink allergies, sensitivities or intolerances? Yes No _____________________________ Do you smoke? Yes No I used it for: _______ years
Are you/have you been exposed to second-hand smoke? Yes No Do you take probiotics? Yes No Do you take Vitamin D? Yes No
Health History 2
3 ©2020 SHAPE ReClaimed
Mental/Emotional Health
Rate the current level of personal stress in your life: None Low Moderate High Rate the current level of relationship stress in your life: None Low Moderate High Rate the current level of health stress in your life: None Low Moderate High Rate the current level of family stress in your life: None Low Moderate High Rate the current level of occupational stress in your life: None Low Moderate High
How do you manage the stress in your life? ______________________________________________________________
I __________________________________________________________ , hereby grant permission to receive a professional and complete physical examination and consultation, including urinalysis and evaluation.
____________________________________________________ _______________________________________
SHAPE Program
Informed Consent & Acceptance of Responsibility
Patient/Client Informed Consent:
I, _________________________________, understand that the SHAPE Program is a lifestyle modification and health restoration program designed to help me improve my overall health. This program is not intended to replace the guidance of my primary healthcare experts. While this program is not used to diagnose, treat, cure or prevent any disease, I understand any medications I am currently taking may need dose adjustments. I agree to notify my prescribing physician that I am working with _________________________________ and will be closely monitored while
incorporating this program for embracing a healthier lifestyle. I understand an anti-inflammatory nutrition protocol will be recommended based on my unique health history, urinalysis and symptoms.
SHAPE Practitioner/Office/Clinic Statement of Intent:
I/We, _________________________________, understand that my/our intent and responsibility is to determine if the SHAPE Program would be beneficial for assisting your body in its innate healing process. Our first appointment with you will be multi-faceted. We agree to do the following:
o Take full health history and assess your unique needs. o Discuss your health goals.
o Perform a baseline urinalysis.
o Make specific recommendations as necessary (nutrition, supplements, diagnostics). o Determine a follow-up schedule.
Patient/Client Acceptance of Responsibility:
I have been informed and understand that nutritional and lifestyle recommendations may involve certain risks. These may include, but are not limited to, detoxification symptoms, such as: initially feeling worse due to the release of stored toxins, digestive symptoms, fatigue, headaches, muscle or joint pain, allergic reactions or any unpredictable reaction with my prescribed medications that has not been found in research literature. In addition, I agree to do the following:
o Submit full health history. o Discuss my health goals.
o Have consistent urinalyses and follow-up visits as recommended by my SHAPE practitioner. o Read the Program Guidebook.
o Review the information provided on the SHAPE ReClaimed website.
o Be aware that I can join the “OFFICIAL SHAPE ReClaimed Support Group” on Facebook and will not substitute recommendations from Facebook for my specific health needs.
I have read (or have had read to me) the above information. I have had the opportunity to ask questions about its contents and by signing below, I agree to these conditions for the duration of my SHAPE Program journey.
