Basic Information About Your LifeStyle

How Do You Feel?	Fantastic	Well	OK	Poorly	Very Poorly
Weight Goal	Lose		Maintain		Gain
Level of Stress	Low	Average	High	Very High	N/A
Aerobic Sessions/Week	0	1-2	3-5	6+	N/A
Anaerobic Sessions/Week	0	1-2	3-5	6+	N/A
Alcohol: Beer (Each Week)	0	1-2	3-5	6+	N/A
Alcohol: Wine (Each Week)	0	1-2	3-5	6+	N/A
Alcohol: Liquor (Each Week)	0	1-2	3-5	6+	N/A
Caffeine: Chocolate Each Day	0	1-2	3-5	6+	N/A
Caffeine: Soda Each Day	0	1-2	3-5	6+	N/A
Caffeine: Coffee Each Day	0	1-2	3-5	6+	N/A
Caffeine: Tea Each Day	0	1-2	3-5	6+	N/A
Smoking: Packs Each Day		0	1-2	2+	N/A
Number of 8 oz Glasses of Water Each Day		0-3	4-6	7+	N/A
Type of Drinking Water		Tap	Distilled	Spring	N/A
Exposure to Chlorine Each Week		0	1-3	4+	N/A
Libido			Lacking	Healthy	N/A
Sleeping			Fitfully	Soundly	N/A

Your Personal Medical History

Skin Disorders	Acne	Psoriasis	Skin Cancer	Loss of Pigment
Loss of Hair From	None	The Head	The Body	Both Head & Body
Diabetes	Migraines	Osteoporosis	Cancer	Heart/Cardiovascular Disease
Arthritis	Depression	Kidney Disease	Liver Disease	High Blood Pressure

How frequently do you move your bowels?
More Than Twice a Day	Twice a Day	Once a Day
3-6 Times a Week	Two Times a Week or Less	N/A

Women Only

Use BC Pill

Hormone Replacement Therapy:

Natural Prescription

Hormone Disorder:

Have PMS Fertility Disorder

Supplements, Please Check All That Apply

Multi-Vitamin	Acidophilus	Echinacea	Lutein	Potassium
Vitamin A	Lysine	GLA	EPA	Creatine
Vitamin E	Fiber	Chromium	Calcium	Magnesium
Vitamin C	Iron	Zinc	Protein Drink	Laxatives
Vitamin B		Other

Client Comments

Signing the Doctor Notification Agreement does not require you to have a doctor or to notify your doctor. This is your choice.

DOCTOR NOTIFICATION AGREEMENT

The undersigned agrees that it is his or her responsibility to deliver all laboratory test results, now and in the future, to his or her own physician for any medical interpretation or opinion regarding any laboratory results provided by YFH^?.  YFH^? does not diagnose, cure or treat any illness or disease.  Available Out of Laboratory Reference Range results will be indicated on the Official Lab Result form provided by YFH^? from their Nationally Certified Lab Contract Partners to the undersigned.  The Laboratories? Medical Directors will review these laboratory test results.  However, this information is not intended to, cannot, and should not be expected to, substitute for a personal consultation with his or her own physician.  Further, the undersigned releases YFH^?, their collection sites, their lab partners, their independent representatives, and affiliates from any and all liability for any failure to identify any medical condition or disease.  It is understood and agreed that this is not the purpose of their services. 

The undersigned agrees that he or she will receive a nutritional interpretation (unless it was a Test Only order) of the test results from YFH^? that are to be used by the undersigned exclusively, as an educational tool, for personal health purposes.  However, the physician of the undersigned can use these same laboratory results to diagnose and treat disease.  The information (as applicable) on the Your Future Health web site, YFH^? brochures, Guide^?, Personal Normal Tracker^?, Health ScoreCard^? as well as results and information packets are believed to be extremely accurate but such accuracy cannot be guaranteed by YFH^?, their independent representatives, and/or affiliates as we are not the originators of the underlying data.  The undersigned also agrees that YFH^? neither recommends nor warrants the suggestions of any health professional or person chosen by the undersigned to assist the undersigned with understanding or interpreting the laboratory results and/or the nutritional interpretation, whether the name is provided by YFH^? or chosen from an independent source.  It is further agreed that the undersigned waives and releases YFH^? from any liability for any injury or loss arising out the use of, or reliance on the recommendations, laboratory results and/or the dietary and lifestyle suggestions provided by YFH^? and/or any health professional or person, including any and all claims of negligence and/or product liability.  Before making any changes to the exercise or diet of the undersigned, a health professional or doctor should be consulted.                 

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Insurance, Medicare, Medicaid Policy

The undersigned agrees that YFH^? does not accept or work with any insurance, Medicare, or Medicaid plans because all YFH tests are ordered for prevention and educational purposes. Under no circumstances can YFH be involved with Insurance, Medicare or Medicaid plans with or without your personal doctor's assistance.

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