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Appointment Form
Personal Information for Consult at the Delgado Protocol
Please fill in form as entirely as possible to the best of your knowledge.
NAME:
*
Explain the reason for your visit.
In this window: Write us a brief note explaining why you wish to visit the Delgado Protocol. Please include the services you are interested in, when you would like to visit and the best way to contact you.
GENDER:
*
MALE
FEMALE
AGE:
EMAIL:
PHONE:
SKYPE ID:
OCCUPATION:
Is your occupation stressul?
YES
NO
How did you hear about the Delgado Protocol?
Please briefly explain in this window...
Your body measurements in inches:
Please list your health goals:
*
Please briefly list your health goals in this window...
Substances:
*
Drink alcohol regularly
Smoke
Drink coffee regularly
Please list all prescription medications, synthetic, or over the counter products you use:
Please briefly explain in this window...
List all supplements, vitamins, herbs and hormones that you are currently taking (you may copy labels and fax in with questionnaire):
*
Please briefly explain in this window...
Have you ever taken any supplements, vitamins, hormones, thermogenics, or medication that has caused you discomfort or did not work? If so, please list:
Please briefly explain in this window...
What is the amount of water you drink each day in cups or liters? (Do not include coffee, soda, etc.)
What percentage of your diet is in pure, unheated, raw foods?
*
0%
10-25%
25-50%
50-90%
What is the percent or grams of fat that you consume each day?
*
2-20 grams
20-80 grams
80+ grams
What is the percent or grams of simple(sugar, soda) and complex carbohydrates (veggies, fruit, brown rice) that you consume each day?
*
0-20 g limited simple sugar
20-100 excess sugar
100-300 complex carb
DAIRY: (Ice Cream, Milk, Eggs, Chease, Yogurt) Check your Dairy usage:
None
1-3 times per week.
3-6 times per week.
6-9 times per week
more than 9 times per week
MEATS: (Beef, Pork, Chick, Turkey, Fish, Liver, Hamburger, Pizza, Tacos, Sausages etc.) Check your Meat usage:
None
1-3 times per week.
3-6 times per week.
6-9 times per week
more than 9 times per week
OILS: Olive Oil, Vegetable Oil, Lard, Butter, Mayo, Fried Foods Check your oil usage:
None
1-3 times per week.
3-6 times per week.
6-9 times per week
more than 9 times per week
COFFEE: (Latttes, Mochas etc.) Check your coffee usage:
None
1-3 times per week.
3-6 times per week.
6-9 times per week
more than 9 times per week
SODA: (Including diet soda) Check your soda usage:
None
1-3 times per week.
3-6 times per week.
6-9 times per week
more than 9 times per week
ALCOHOL: (Beer, Wine, Liquor) Check your alcohol usage:
None
1-3 times per week.
3-6 times per week.
6-9 times per week
more than 9 times per week
PASTA: (include White Bread, Cereal) Check your pasta usage:
None
1-3 times per week.
3-6 times per week.
6-9 times per week
more than 9 times per week
FRESH FRUIT:
None
1-3 times per week.
3-6 times per week.
6-9 times per week
more than 9 times per week
WHOLE GRAINS:
None
1-3 times per week.
3-6 times per week.
6-9 times per week
more than 9 times per week
SALT:
None
1-3 times per week.
3-6 times per week.
6-9 times per week
more than 9 times per week
Do you eat at resteraunts?
YES
NO
If so, how often?
DIETS: Please indicate diet programs that you have tried in the past:
Atkins (High Fat, Protein)
Carb Busters
Suzanne Sommers (High Fat, Medium Carb)
Weight Watchers
Richard Simmons
Ornish, Pritikin, McDougall
Barry Sears Zone Diet
South Beach Diet
Vegetarian
Raw Food Vegan
Macrobiotic
Delgado Diet
NONE
If applicable, what did you like and dislike about them, and why did they fail to become a regular part of your lifestyle?
Please briefly explain in this window...
Are there situations, moods, or occasions that cause you to eat problem (unhealthy) foods or to eat or drink more than you should?
Stress
Financial Pressure
Fear
Happiness
Relationships/Social Interaction
Other
Please indicate any diet and foods your allergic to or that you intensly dislike:
Please briefly explain in this window...
Exercise Training: If exercise is not part of your weekly routine, Please explain why and list or check any training restriction:
Please briefly explain in this window...
Do you use Weights?
YES
NO
Do you use a training partner?
YES
NO
Aerobic Exercise:
YES
NO
If so, how often?
How long have you adhered to your exercise routine?
What time do you generally go to bed?
Difficulty falling asleep?
YES
NO
What time do you generally wake up in the morning?
Average number hours sleep?
5
6
7
8
9
10
Do you use an alarm clock?
YES
NO
Do you wake up during the night?
YES
NO
Do you set aside time during the day for a nap, meditation, quiet time or prayer? If so, what time of day? for how long?
Do you feel rested upon waking in the morning?
YES
NO
How often do you have sex? Times per week? per day? per month?
Do you achieve orgasm each time?
YES
NO
Is your libido as strong as it was when you were in your 20s?
YES
NO
Interest in improving your libido/sexual function?
YES
NO
MALE: Do you usually wake up with a morning erection?
Seldom
Sometimes
All the time
MALE: Would you like to improve the firmness and frequency of erection?
Seldom
Sometimes
All the time
MALE: Prostate Enlargement?
YES
NO
FEMALE: Describe typical menstrual cycle
LIGHT
HEAVY
FEMALE: Date of last period:
FEMALE: Do you experience cramps, night sweats, hot flashes? Explain:
What is the frequency of your bowel movements?
Once a day
Twice a day
Every other day
OTHER
Are the stools soft and naturally bulky?
YES
NO
Are the stools hard, bullet shaped, straining to expel?
YES
NO
Are you constipated?
YES
NO
What color is your urine?
Mostly Clear
Mostly Yellow
Frequent Night time urination?
YES
NO
How many times per night?
