Fat Storage VS Fat Burning checklist · Fat Storing VS Fat Burning WHY YOU MAY NOT BE TRIGGERING...

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VS Fat Storing Fat Burning WHY YOU MAY NOT BE TRIGGERING YOUR FAT BURNING HORMONES Have you ever dieted, lost weight and put it back on and then repeated losing weight and gaining it back? This roller-coaster effect causes the loss of muscle mass. Most people do not diet correctly. This causes the body to burn muscles for energy. Muscles require more energy keeping your metabolism high. When you lose muscle mass your metabolism slows down and so does your fat burning capacity. Have you ever completed a diet, yet still returned to your original weight? To allow your body to have a new normal weight it needs to maintain the new weight for approximately 6 months in order for it to become your new normal. Does emotional baggage overpower you? Eating for the wrong reasons, using food as an emotional comfort for when you are depressed or a celebration when you are happy puts on fat. Do you overconsume alcohol? Alcohol triggers insulin, which stimulates the body to store fat, thus causing weight gain. Do you skip meals or let yourself get too hungry? Skipping meals, reducing calories and letting yourself get hungry makes the body think it should store fat. It goes into survival mode. Do you eat refined grains, white bread, cakes, cookies, etc.? Eating refined carbohydrates, refined sugars and refined grains (white bread, cakes, cookies, etc.) all stimulates insulin production, which stimulates fat storage. Do you have recurring or chronic pain? Cortisol is your body's anti-inflammation hormone. It is released when you're in pain but when cortisol is elevated it controls the body to hold onto fat. This hormone causes the storage of belly fat, so getting any body pains reduced helps put you in a fat burning mode. Do you eat to the point of feeling discomfort? Overeating stimulates fat storage hormones. What you don't need the body stores. Do you overconsume caffeinated drinks like coffee or sodas? Caffeine stimulates cortisol, which triggers fat storage. Do you carry a lot of stress? Stress causes an increase in the hormone cortisol, which blocks weight loss and puts you in the fat storage mode. Do you have poor sleeping habits? If your body is not well rested; metabolism is reduced and puts you into a fat storage mode. Do you drink tap water or does your diet consist of packaged foods? There are over 80,000 chemicals in our food and water unless your diet is completely organic and you drink only pure water. They make us toxic and the body puts these toxins into fat cells, which triggers more fat storage.

Transcript of Fat Storage VS Fat Burning checklist · Fat Storing VS Fat Burning WHY YOU MAY NOT BE TRIGGERING...

Page 1: Fat Storage VS Fat Burning checklist · Fat Storing VS Fat Burning WHY YOU MAY NOT BE TRIGGERING YOUR FAT BURNING HORMONES Have you ever dieted, lost weight and put it back on and

VS Fat Storing Fat Burning WHY YOU MAY NOT BE TRIGGERING YOUR FAT BURNING HORMONES

□ Have you ever dieted, lost weight and put it back on and then repeated losing weight and gaining it back? This roller-coaster effect causes the loss of muscle mass. Most people do not diet correctly. This causes the body to burn muscles for energy. Muscles require more energy keeping your metabolism high. When you lose muscle mass your metabolism slows down and so does your fat burning capacity.

□ Have you ever completed a diet, yet still returned to your original weight? To allow your body to have a new normal weight it needs to maintain the new weight for approximately 6 months in order for it to become your new normal.

□ Does emotional baggage overpower you? Eating for the wrong reasons, using food as an emotional comfort for when you are depressed or a celebration when you are happy puts on fat.

□ Do you overconsume alcohol? Alcohol triggers insulin, which stimulates the body to store fat, thus causing weight gain.

□ Do you skip meals or let yourself get too hungry? Skipping meals, reducing calories and letting yourself get hungry makes the body think it should store fat. It goes into survival mode.

□ Do you eat refined grains, white bread, cakes, cookies, etc.? Eating refined carbohydrates, refined sugars and refined grains (white bread, cakes, cookies, etc.) all stimulates insulin production, which stimulates fat storage.

□ Do you have recurring or chronic pain? Cortisol is your body's anti-inflammation hormone. It is released when you're in pain but when cortisol is elevated it controls the body to hold onto fat. This hormone causes the storage of belly fat, so getting any body pains reduced helps put you in a fat burning mode.

□ Do you eat to the point of feeling discomfort? Overeating stimulates fat storage hormones. What you don't need the body stores.

□ Do you overconsume caffeinated drinks like coffee or sodas? Caffeine stimulates cortisol, which triggers fat storage.

□ Do you carry a lot of stress? Stress causes an increase in the hormone cortisol, which blocks weight loss and puts you in the fat storage mode.

□ Do you have poor sleeping habits? If your body is not well rested; metabolism is reduced and puts you into a fat storage mode.

□ Do you drink tap water or does your diet consist of packaged foods? There are over 80,000 chemicals in our food and water unless your diet is completely organic and you drink only pure water. They make us toxic and the body puts these toxins into fat cells, which triggers more fat storage.

Page 2: Fat Storage VS Fat Burning checklist · Fat Storing VS Fat Burning WHY YOU MAY NOT BE TRIGGERING YOUR FAT BURNING HORMONES Have you ever dieted, lost weight and put it back on and

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The following form is provided so we can get a basic understanding of your current wellness and weight situation. The form is involved because the body has many intricacies and interdependencies between its varying systems. Imbalances in any of these systems can lead to pain, sickness, depression, weight gain or a host of other symptoms. By filling this form out to the best of your ability, you are better able to help yourself and help us help you.Some questions may seem sensitive to you, but, by law, all of the information you give us is protected and only dietWELL doctors, practitioners, administrators and our trained Health Coaches -- only when they are involved in your direct care -- will ever see the information on this form. It will not be shared with anyone else. If you still do not wish to share certain information with us, it is your right to do so, but please remember that not sharing this information limits our ability to help you and, therefore, limits your body's ability to heal itself.

Last!Name:!____________________________! !First!Name:!_________________________!! DOB:!____/____/____/!!

________!Initials!

Date: _____/_____/_____/

ietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client s health status in order to guide his or her weight loss plan. client may be advised to seek medical advice based on his or her health profile.

1. General:(Please'QSJOU�DMFBSMZ)'Last Name: _____________________________________ First Name: ___________________________________ Address: ______________________________________________________________ Apt/Unit: # _____________ City: ______________________________ State: _____________________ Zip/Postal Code: _________________

Phone: ______________ Cell: ____________________ Email: ____________________@____________________

Date of Birth: _______/_______/_______/Age: __________* Profession: __________________________________

Who may we thank for referring you?_______________________________________________________________

Current Weight:____________ lbs. Height:_________ How much weight would you like to lose?:__________lbs.

Minimum adult weight: ______________ lbs. at age _________ Maximum adult weight: ____________ lbs.

Do you exercise? � Yes � No If yes, what kind? _____________________________________________________

How often? � Daily � Weekly � Other: ____________________________________________________________

Have you been on a diet before? � Yes � No -If yes, please specify which diet(s) and why you think it didn’t

work for you (e.g. too rigid, too much cooking involved, etc.):_____________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Health Profile

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!2. Support SystemAfter 18 months, people who reduced their calorie intake and had another person regularly check in with them a out their progress lost almost twice as much weight as those who didn t ha e a support system ocial support adds accounta ility A friend, family mem er or co worker can e your weightloss mentor, the important thing is to re iew your progress together at least weekly

ell us who will e in your support system from your

amily riend o orker

hone hone hone

f these people, who would e the most supporti e

DOB:!____/____/____/!Last!Name:!____________________________! !First!Name:!_________________________!!!

________!Initials!

On a scale of 1 to 10, indicate what level of importance you give to losing weight via a professionally supervised weight loss method?: (circle one) Least important 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 Very/Most Important

What is your marital status? M / S / D / W /other Do you have children? � Yes � NoHow many children do you have? ________ How old are your children ____________________________________

On average, how many hours do you sleep per night?__________________________________________________

Who is your primary care physician (family doctor)? ____________________________________________________

Physician List: Please list any physicians you see and their specialty (refer to medical information for list of disorders):

Specialty: ____________________ Patient since: ____/____ (mo/yr)

Specialty: ____________________ Patient since: ____/____ (mo/yr)

Specialty: ____________________ Patient since: ____/____ (mo/yr)

Specialty: ____________________ Patient since: ____/____ (mo/yr)

Specialty: ____________________ Patient since: ____/____ (mo/yr)

Dr. ____________________________

Dr. ____________________________

Dr. ____________________________

Dr. ____________________________

Dr. ____________________________

What made you want to do something about your weight today?__________________________________________

_____________________________________________________________________________________________

How is being overweight affecting your life?__________________________________________________________

_____________________________________________________________________________________________

Do you have a special occasion or an event that you'd like to lose weight for? _______________________________

How would losing weight improve the quality of your life in regards to your:HEALTH? ____________________________________________________________________________________ WORK? _____________________________________________________________________________________ RELATIONSHIPS? ____________________________________________________________________________ HOBBIES? ___________________________________________________________________________________

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Last!Name:!____________________________! !First!Name:!_________________________!! DOB:!____/____/____/!!

________!Initials!

� Yes � No (If not, please skip to next section)

. Diabetes:

Do you have diabetes?

Which type?

a � Type I

b.� Type II

c.� Type II

- Insulin-dependent (insulin injections only -NC)

- Non-insulin-dependent (diabetic pills)

- Insulin-dependent (diabetic pills and insulin)

Is your blood sugar level monitored � Yes � No If so, how often? ____________________________________

If so, by whom? � Myself � Physician � Other (Please specify): ________________________

Do you tend to be hypoglycemic? �Yes � No

. Cardiovascular Function:Have you had any of the following cardiovascular conditions?

� Heart Attack (NC)

� Blood Clot (NP)

� Pulmonary Embolism (NP)

� Stroke or TIA (NP)

e � Coronary Artery Disease (NP)

� Heart Valve Problem (NP)

� Heart Valve Replacement – porcine / mechanical (NP)

��Arrhythmia (NP - if on Rx medications)

��Hypertension (High blood pressure)(NP)

��Hyperlipidemia (High cholesterol/triglycerides)�

��Hypokalemia (Low Potassium) (NP)

��Hyperkalemia (High Potassium) (NP)

m ���Congestive Heart Failure (NP)

Have you ever had ANY type of heart surgery? � Yes � No

If so, which type? _______________________________________________________________________

Other conditions: _________________________________________________________________________

If you have answered yes to any of these conditions, please give dates of occurrence. For multiple conditions, please

__________________________________________

__________________________________________

__________________________________________

specify: _______________________________________

_______________________________________

_______________________________________

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Last!Name:!____________________________! !First!Name:!_________________________!! DOB:!____/____/____/!!

________!Initials!

#5.#Kidney#Function:#Have you had:

a.Kidney St ones Yes � No Date: ____/____/b. e � e �

d.Do you have Gout? � Yes � No If so, since when? ___/___/

If so, what medication has been prescribed? ____________________________________________________

If no, have you ever had Gout? � Yes � No If so, when? ____/____/

If yes to any of these events, please give dates of events. For multiple events please specify:

_______________________________________ __________________________________________

_______________________________________ __________________________________________

_______________________________________ __________________________________________

!

# . #Liver#Function:#

a. Have you had any liver issues? (NP) � Yes � No Date: ____/____/

__________________________________________

__________________________________________

!

If yes, please list:_______________________________________

_______________________________________

!

. Colon Function:Do you have:

� Yes � No � Yes � No � Yes � No � Yes � No

a. Irritable Bowel Syndromeb. Diverticulitisc. Constipation � Yes � No

d. Ulcerative Colitise. Crohn’s Diseasef. Diarrhea � Yes � No

If yes to any of these events, please give dates of events. For multiple events please specify:

__________________________________________

__________________________________________

__________________________________________

_______________________________________

_______________________________________

_______________________________________

c. e e e e e� �

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Last!Name:!____________________________! !First!Name:!_________________________!! DOB:!____/____/____/!!

________!Initials!

. Digestive Function:

Do you have: a. Acid Reflux � Yes � No � Yes � No b. Heartburn � Yes � No

e. Gastric Ulcer f. Celiac Disease � Yes � No

c. Are you Gluten intolerant? � Yes � Nod. History of Bariatric Surgery (NC) � Yes � No

If so, what type of bariatric surgery?________________________________________________________

! . Ovarian/Breast Function: Please check the situations that apply to you currently:a. Irregular Periods � Yes � No e. Menopause � Yes � No b. Fibrocystic Breasts � Yes � No f. Painful Periods � Yes � No c. Hysterectomy � Yes � No g. Heavy Periods � Yes � No d. Amenorrhea � Yes � No h. Uterine Fibroma � Yes � No Date of last menstrual cycle: ____/____/____/Are you on oral birth control pills? � Yes � Noi. Are you pregnant? � Yes � No j. Are you breastfeeding? � Yes � No

. Endocrine Function:a .Do you have thyroid problems? � Yes � No If so, please specify: ___________________________ b. Do you have parathyroid problems? � Yes � No If so, please specify: ___________________________ c. Do you have adrenal gland problems? � Yes � No If so, please specify: ___________________________

Have you been told you have Metabolic Syndrome (also called “Syndrome X”)? � Yes � No

ys Stru tur u t o

o any of these apply to you

.� nee pain d.� eck paina.� ow ack pain

e.� eadaches f.� ciatica leg pain

c.� houlder pain

g.� arpal unnel yndrome arm pain h.� oot pain flat feet

other issues

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DOB:!____/____/____/!Last!Name:!____________________________! !First!Name:!_________________________!!!

________!Initials!

� Yes � No � Yes � No � Yes � No � Yes � No

Depression � Yes � No

f. Panic Attacksg. Anorexia (History of)h. Bulimia (History of)i. Schizophrenia

Anxiety � Yes � No

a. Bipolar isorder � es � o b. arkinson s disease � es � o

Epilepsy (NP) � Yes � No d. l heimer s disease � es � o

e.

!

Other issues: ______________________________________

!

1 . Inflammatory Conditions:

Do any of the following apply to you? a.� Migraines d.� Fibromyalgia f.� Rheumatoid g.� Lupus

e.� Chronic Fatigue Syndrome h. � Multiple Sclerosis i. � Osteoarthritisb.� Psoriasisc.� Other autoimmune or inflammatory condition

!

1 . Cancer:Do you have Cancer? (NC)

If so, what type and where is it located?

Have you ever had Cancer? (NC)

If so, what type and where is it located?

� Yes � No

______________________________________________________

� Yes � No

_______________________________________________________ When was the Cancer diagnosed? ____/____/____/

c. Is your Cancer in remission? (NC) � Yes � NoIf so, how long have you been in remission? __________________ (mo/yrs)

� Yes � No

__________________________________________

__________________________________________

!

1 . General:Do you have any other health problems?

If so, please specify:

_______________________________________

!_______________________________________

!

1 . Allergies:Do you have any food allergies or sensitivities? � Yes � No

__________________________________________

__________________________________________

o any of the following apply to you

e

If so, please list

_______________________________________

_______________________________________

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Last!Name:!____________________________! !First!Name:!_________________________!! DOB:!____/____/____/!!

________!Initials!

!

1 . Eating Habits(Please be as honest as possible so that we may better help you)

Breakfast

� Yes � Sometimes � Never Do you have breakfast every morning? Approximate time:

Examples: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

� Yes � Sometimes � Never Do you have a snack before lunch? Approximate time:

Examples: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Lunch

� Yes � Sometimes � Never Do you have lunch every day? Approximate time:

Examples: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

� Yes � Sometimes � Never Do you have a snack before dinner? Approximate time:

Examples: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Dinner

� Yes � Sometimes � Never Do you have dinner every day? Approximate time:

Examples: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

� Yes � Sometimes � Never Do you have a snack at night? Approximate time:

Examples: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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DOB:!____/____/____/!

________!Initials!

Are you a vegan? � Yes � No

(Strict Vegans do not qualify due to too many dietary restrictions)

Are you a vegetarian? � Yes � No

How many glasses of water do you drink per day? ______ glasses per day

How many cups of coffee do you drink per day? ______ cups per day

� Yes � No

for how many years? ____________

Do you smoke?

If so, packs per day

Do you drink alcohol? � Yes � No

If so, what and how often? _______________________________________________________________________________

Not Permissible on the Protocol - No potential dieter is to be placed on the dietWELL Weight Loss Protocol with or without the consent of his or her primary care provider or monitoring specialist with any of the following contraindications:

Severe kidney disease or kidney transplantSevere liver diseaseEpilepsy

iagnosis or history of Congestive Heart ailure CHatients currently on Lithium therapyatients with a diagnosis of arkinson's isease

Individuals maintaining a strict vegan lifestyleBreast-feeding female

regnant female note from B L

• History of a cardiovascular event (i.e.: heart attack, stroke, aneurysm, bypass, stentsurgery, blood clot, pulmonary embolism, TIA, coronary arer disease, heart valveproblem, heart valve replacement, arrhythmia, hypertension, hypokalemia, hyperkalemia,cardiac arrhythmia, any type of heart surgery)• History of or current active cancer, including skin cancers• Insulin Dependent Type 1 Diabetic (insulin injections only)• History of Bariatric surgery

Last!Name:!____________________________! !First!Name:_________________________!! !

Relative Contraindications - I have read and understand the Relative Contraindications noted below and what is not permissible on the program. If I have any of these

conditions or diagnoses I have discussed this with my primary care provider or specialist and have his or her consent. No potential dieter is to be placed on the dietWELL Weight Loss Protocol with a history of or current diagnosis of the following conditions without consent from his/her primary care provider or specialist monitoring specified condition:

Page 10: Fat Storage VS Fat Burning checklist · Fat Storing VS Fat Burning WHY YOU MAY NOT BE TRIGGERING YOUR FAT BURNING HORMONES Have you ever dieted, lost weight and put it back on and

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Last!Name:!____________________________! !First!Name:!_________________________!! DOB:!____/____/____/!!

________!Initials!

a.� I don't think I need them b.� I have difficulty swallowing pills

c.� I'm confused about all the different information about vitamins

Are you currently taking vitamins herbs or supplements?

If you are not taking any vitamins herbs or supplements why?

Check all that apply:

d.� I forget to take them

You must take vitamins and minerals while you are on the dietWELL Weight Loss Program.

I understand the above statement and agree to take the required supplements. ______________________ (initial)

* or grams, mEq or dosage unit your doctor prescribes.

Name of Medication

How many mg is each tablet? *

How many tablets do you take each day?

How often do you take a

dose?

Prescribed by whom?

Why do you take this

medication?

Vitamin X 500 mg 1 1 x a day Dr. John Doe Omega 3

!Dear Client : Please complete this form by listing all prescription medications and supplements that you are currently taking. We have provided an example on the first line below of how this form should be completed.

� Yes � No

Do you have any medical implants or joint replacements?

18. Medication:Vitamins Herbs and Supplements

� Yes � No

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Last!Name:!____________________________! !First!Name:!_________________________!! DOB:!____/____/____/!!

________!Initials!

CONFIRMATION OF FULL HEALTH STATUS DISCLOSURE BY THE CLIENT AND AGREEMENT TO ARBITRATE DISPUTES

I confirm that the information that I have provided and that is recorded by me on this dietWELLTM Health rofile is true, complete and accurate and that I have not withheld or otherwise omitted, whether in whole or in part, any information concerning my health status. In this respect, I confirm that I have disclosed all past and present i physical and or mental health problems or concerns that I have e perienced, ii diagnoses and or surgeries that I have had, and iii medications and supplements that were prescribed to me or that I have taken.

Without limitation to the foregoing, I specifically confirm that I do not have any of the conditions identified as NC or NP on this form. urthermore, I understand that I should not be undertaking or otherwise following the dietWELLTM Weight Loss rogram if I have any of the said conditions or if I am currently taking any medications to treat these conditions unless i I specifically consult with a medical doctor concerning my suitability to go on the dietWELLTM Weight Loss

rogram, ii remain under the supervision of said medical doctor while I am on the dietWELLTM Weight Loss rogram, and iii and provide documentation confirming the foregoing.

I understand that if i I have any of the aforementioned conditions or if I am currently taking any of the aforementioned medication, ii have not disclosed same to the clinic and iii nevertheless chose to go on the dietWELLTM Weight Loss

rogram without specific supervision, such decision will be completely voluntary, and I release and discharge the clinic as well as dietWELL, its parent companies, subsidiaries and affiliates and their respective shareholders, directors, employees, agents, representatives, successors and assigns collectively, the eleasees from any and all damages, liability, claims and causes of action of any nature whatsoever including for in ury, illness or death that may result from such voluntary and informed decision.

I confirm that the dietWELLTM Weight Loss rogram has been e plained to me, that I have had the opportunity to ask questions relating to the dietWELLTM Weight Loss rogram, that I have been provided with the answers to such questions and that I understand the importance of strictly following the dietWELLTM Weight Loss rogram as e plained to me verbally and in the materials provided to me, both before and during the period I will be following the dietWELLTM Weight Loss rogram.

Without limitation to the foregoing, I confirm that I have been advised that because the dietWELLTM Weight Loss rogram limits the ingestion of certain foods, it is important that I consume the recommended supplements while I am

on the dietWELLTM Weight Loss rogram.

I undertake to disclose immediately to the clinic any and all changes in my health status, discomfort, symptoms or other health concerns that I may e perience while I am on the dietWELLTM Weight Loss rogram. I specifically agree that all claims against any of the eleasees that I may have or choose to make shall only be submitted to binding arbitration under the rules and guidelines of the merican rbitration ssociation, and I waive any rights to pursue any claims or causes of action in any court of law.

I specifically agree that all claims against any of the Releasees that I may have or choose to make shall only be submitted to binding arbitration under the rules and guidelines of the American Arbitration Association, and I waive any rights to pursue any claims or causes of!action in any court of law. !

#

!SIGNED IN ____________________ (City/State), on this ____ day of _________, 2017

_________________________________________ (Signed) Name of client (print):________________________

Witness:

______________________________________ (Signed) Name of witness:________________________