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iHEALTHe Institute Health Info Form

Welcome to the iHEALTHe Institute! We want to reassure you that all the information that you provide in this form is PRIVATE and CONFIDENTIAL. This form is reviewed by a healthcare professional on our team. Once you complete the health info form, you will receive an email back from the healthcare team giving you the go ahead to begin the program. If further consultation is required, you will be notified.

Personal Information:

First Name *

Last Name *

Email *

Gender *

Male Female

Referred By (if any):

Phone *

Street Address 1 *
Street Address 2
City *
State *
Postal Code *
Zip Code
Country *

What is your current age? *

What is your height? (in feet and inches) *

What is your weight:? (in pounds) *

What is your goal weight? (in pounds, ie 130 lbs) *

What is your marital status? *

Single MarriedDivorcedCommon Law

What is your current occupation? *

Health Questions:

Are you a smoker? *

YesNo

How much alcohol do you consume? *

NoneMinimalModerateHeavy

Do you have any allergies? (seasonal, cats, foods, etc) *

YesNo

How would you describe your immune system? *

WeakAverageStrong

Exercise and Stress:

Indicate your exercise level: *

No exerciseMild exerciseOccasional vigorous exerciseRegular vigorous exercise

Please indicate the type of exercise? (yoga, running, weights) *

What is your daily stress level from 1-10? (1-light, 10-extreme) *

Please describe your stress, if any:

Liquid Intake:

Describe your daily thirst level: *

Never too thirstyAverageExcessive

What is your daily liquid intake? (in liters) *

What do you prefer to drink? (water, coffee, pop, alcohol etc)) *

How do you prefer your drinks to be? *

HotWarmColdIced

Your Heart and Circulation:

Do you have angina/palpitations? *

YesNo

If yes, since when?

Do you have hypertension/hypotension? *

YesNo

If yes, since when and when does it occur?

If yes, are you taking any medications for it?

YesNo

If yes, please specify. (thiazide, diuretics etc)

Do you have circulation problems? (varicose veins, diabetes etc) *

YesNo

Other Field

Your Limbs and Joints:

Do you have inflammation? (in your knees, fingers, ankles etc) *

YesNo

If yes, please specify where and when it flares up.

Are you taking any medications for the condition?

YesNo

If yes, how is your body responding to the treatment?

Do your extremities ever experience any of the following? *

NumbnessCrampsOn pins and needlesNo issues

Your Temperature and Perspiration:

Choose what best describes your body temperature: *

HotWarmAverageChilly

How do you prefer your room temperature? *

HotWarmCoolStuffyChilly

Where do you normally perspire? *

Normally on my headNormally on my handsNormally on my feetNormally on my bodyNo perspiration

When do you perspire most often? *

Physical activityMental exertionStressful situations

Further Health Questions:

Have you had any recent changes to your weight, energy levels, or sleep? *

YesNo

If yes, please specify. (weight gain, nightmares etc)

Are you currently on any medications? *

YesNo

If yes, please list with dosage amounts.

Why do you currently want to lose weight? *

How long have you struggled with your weight?

Have you tried other weight loss programs? *

YesNo

If yes, please list what programs you have tried.

What were your results and were they permanent?

How long did you keep the weight off?

Do you currently take nutritional supplementation? *

YesNo

If yes, please list the supplements. (vitamin D, B12 etc)

Do you have health challenges that you feel is important for us to know about? *

YesNo

If yes, please specify.

Member Declaration:

I hereby consent to guidance while on the iHEALTHe 31-Day Reset and 14-Day Sustain Plan. The iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan is a self-directed fat loss program that is designed to maximize fat loss by using specific combinations and blends of specific low glycemic index/anti-inflammatory foods in combination with the iHEALTHe 31-Day Reset and 14-Day Sustain Plan nutritional support formulas. These formulas are approved by Health Canada with Reset Formula DIN number "DIN-HM 80053320", and Sustain Formula DIN number "DIN-HM 01965158". I agree to follow the program designed or modified by the iHEALTHe Institute healthcare specialists which includes Fadia Habib who is the Homeopath and Chief Wellness Officer of the iHEALTHe Institiute. I also understand that the cost of the program is designed to include the cost of coaching, assessment, program materials and supplies. I agree to the following: I will eat every component of every meal as described. I will not skip any meals. I will take my spray as scheduled and will not miss taking them. I will not drink alcohol. I will not take any Essential Fatty Acid supplements while on the iHEALTHe 31-Day Reset Plan. I will fill out my daily journal. I will drink my daily amount of recommended water. In order to achieve my desired goals, I agree not to quit or give up. I will be honest with myself and agree NOT TO DO things that are not in alignment with the program. I understand that once I have started my health gain / fat loss program there are NO refunds. I also understand that my program is Non-transferable. I understand that fat loss is NOT GUARANTEED with this program, but that other members have experienced positive results while on the program. I understand that I undertake this program entirely at my own free will and risk and that my healthcare specialists will endeavor to take all due care. I understand that my healthcare specialists will rely on statements made by me to determine that the program is safe and will be effective for me. I have informed the healthcare specialists of all known physical and medical conditions as well as all medications that I am currently taking. I assume all responsibility and liability for any condition(s) or medication(s) I have failed to disclose. I hereby waive any potential claim for liability against the healthcare specialists and the makers of the iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan and freely accept all liability and responsibility for my results while on this program. *

Consent and Release of Liability:

I understand that my use and consumption of any iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan or engaging in any fat loss program including the type that is to be used in conjunction with the iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan, have inherent risks to my health and well-being. Including but not limited to headaches, nausea, dizziness, vomiting, fatigue, pain, shortness of breath and other ailments. I understand as well that rapid weight(fat) loss of over 1-2 lbs. per week is considered by most in the weight loss medical community to be excessive and may lead to ailments similar and in addition to those mentioned above. Therefore, I understand that my failure to follow the fat loss program exactly as described to me by my healthcare team can result in severe temporary and/or permanent medical conditions in addition to those mentioned above. I understand that I am not to use or consume any of the iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan if I am pregnant or think I might be pregnant. I understand that, as a dietary supplement, the iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan has not been approved by the FDA or any Federal or State authority. I additionally understand that The iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan is not meant to diagnose, treat or cure any disease or medical condition and that I am to undergo participation in the iHEALTHe 31-Day Reset Plan and the 14-Day Sustain Plan only under supervision and guidance from my healthcare advisors. I also understand that I should consult with my doctor prior to starting ANY exercise or nutritional supplement program. I understand that, if I experience any ailment, including but not limited to headaches, nausea, dizziness, vomiting, fatigue, pain, shortness of breath and other ailments, I should immediately stop using or consuming the iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan and, if my symptoms do not resolve immediately, I should consult my physician or go to the hospital emergency room. I hereby consent to, and assume the risks associated with, the use and consumption of the iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan and agree to follow the recommendations and instructions of my healthcare team. I further agree not to use or consume any iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan without the advice, counsel, and recommendations of my healthcare team. I hereby release, discharge and agree to indemnify my healthcare team, their agents, servants employees and affiliates from any and all liability, claims, causes of action and demands for personal or bodily injury or death that I or my personal representatives might have or might hereafter acquire through my use or consumption of the iHEALTHe 31-Day Reset Plan and 14-Day Sustain Plan. *