Inches Away Diet Sense & Traveling Diet Coach - Health History Questionnaire

If you would like to enroll with Inches Away Diet Sense, please fill out the following form. After filling out the form and submitting it - you may then proceed to ordering your products.

Please note that all fields are required. Also note that we ask for your current physician's information in order to obtain a complete medical history to ensure our plans are suitable for you.

Name:
Address:
City:
State:
ZIP Code:
Home Phone: (Ex: 123-456-7890)
E-Mail:
Physician's Name:
Physician's Address:
Physician's State:
Physician's City:
Physician's ZIP Code:
Physician's Phone: (Ex: 123-456-7890)
Current Height (in inches):
Current Weight (in pounds):

Do you have diabetes, and require insulin shots?
Have you been diagnosed with heart disease that limits normal activity?
Have you had active ulcers in the past 8 weeks?
Have you had stomach surgery for obesity, including gastric bubble?
Do you have or have you had Colostomy/Illeostomy, Crohn's Disease, severe Lleltis, Colitis, or Chronic Diarrhea?
Are you under treament for, or do you have, Liver Disease or Gallstones?
Have you recently (within 1 year) had or do you have recurring Kidney Stones?
Do you have acute or chronic kidney disease?
Do you have a history of or do you currently have any eating disorders such as Anorexia or Bulimia?
Are you a nursing mother?
Are you undergoing treatment for cancer?
Are you taking MAO Inhibitors, or Anti-Depressant drugs (If yes, please contact us concerning which drug you are taking)?
Are you taking Lithium? If yes, are you taking Diuretics?
Are you pregnant?
Are you lactose intolerant?