Weight Loss Patient History

Patient Information

Patient First Name:

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Patient Last Name:

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Phone Number:

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Cell Phone Number:

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Please indicate which phone number you wish for us to leave messages with medical information

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Email:

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Social Security Number

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Street Address:

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City:

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State:

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ZIP Code:

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Date of Birth:

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PatientAge:

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Marital Status

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Occupation:

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Primary Care Information

Primary Physician Name:

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Primary Physician Phone Number

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Preferred Pharmacy:

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Pharmacy Phone Number:

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Patient Medical History

Your lifetime ( non-pregnant) max weight:

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Your Goal Weight:

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Age when you were last at your goal weight:

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What was your weight 1 year ago?

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What was your weight 5 years ago?

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What was your weight 20 years ago?

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Do you smoke?

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If yes, how much per day / week?

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Drink Alcohol?

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How much?

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The following section is to be filled out by FEMALES only

Are your periods regular?

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If not, do you skip periods?

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What was the date of your last period?

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Do you suffer from infertility?

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Do you have unwanted hair?

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Are you pregnant?

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Do you plan on becoming pregnant soon?

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Are you Breastfeeding?

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Do you plan on becoming pregnant in the next few months?

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Birth control method/s (including both male & female sterilization):

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The following section is to be filled out by MALES only

Muscle Weakness?

Please select an option.

Low Sex Drive?

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Erectile Dysfunction?

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Low Energy?

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Weight Loss History

What have you done in the past to try to lose weight? Check all that apply:

Weight Watchers

Diet Pills

Surgery

Purging / Vomiting

Starvation

NutriSystem

Medifast

Nutrition Consult

Optifast

Jenny Craig

HCG

Atkin's Diet

Low Carb

Overeaters Anonymous

Other

If other, please elaborate:

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Please list any MEDICATIONS you are currently taking, prescribed or over the counter, per line: (name of medication, dosage, frequency, reason for taking it))

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Please list any major surgery, including weight loss surgery, along with the date performed:

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Any know allergies to food or medicine? If yes, please specify allergen & reaction:

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Please check the medical conditions that YOU have been diagnosed with in the past or currently:

High Blood Pressure

High Cholesterol

Heart Disease/Heart Failure

History of Heart Attack

Syncope (Passing Out)

Pacemaker or Defibrillator

History of Heart Valve problems or Arrhythmia

Heartburn / GERD

Thyroid Disease

Liver Disease

Kidney Disease

Asthma

Diabetes (insulin dependent or other injection)

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Diabetes (Oral Medications)

Pre-Diabetes / Metabolic Disorder

Low Testosterone (Men)

PCOS

Arthritis

Drug Abuse

Depression/Anxiety

History of current or past Alcohol Abuse

Bipolar Disorder

Eating Disorder

Glaucoma

Seizures

Anemia

Sleep Disorders / CPAP Use

Cancer

Gout

Stroke

Please list any additional health information that we should know about you:

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Has any blood relative had any of the following? Please select all that apply:

Asthma

Unexplained Death <40 years old

Mental Illness

Alcoholism

Heart Attack

Diabetes or Borderline Diabetes

Glaucoma

Cancer

Overweight

High Blood Pressure

Kidney Disease

High Cholesterol

Heart Disease / Stroke

Exercise History (Exercise You Are Currently Doing)

Exercise Type:

Walking

Swimming

Biking

Other

If other, please specify:

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Exercise Frequency:

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Intensity

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For how long?

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Do you perform any resistance type exercise? (weight lifting or strength straining)

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Do you use a device to monitor your exercise? (FitBit or pedometer)

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Do you have or use a scale?

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Do you have any disabilities that effect your ability to exercise?

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If you have a disability that effects your ability to exercise, please explain:

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Behavior & Lifestyle

Which of the following best describes you? Please check all that apply.

Always hungry

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Liquid Calories (excess alcohol or soda)

Food Cravings (Carbs)

Stress Eating

Food Dominated Life

Social Eating (Only Eating Excessively in Social Settings)

Eating Late or Waking Up to Eat

Mindless Eating / Habit Eating

Eating Until Uncomfortably Full

Weekend Overeating

Eating Too Fast

Boredom Eating

Large Portions

Skipping meals

Other

If you checked "Other", please elaborate:

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How would you rate your readiness for lifestyle changes to reduce your weight?

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Are you willing to keep a food journal?

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How confident are you that you can loose weight at this time?

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How supportive is your family of your weight loss goals?

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How supportive are your friends of your weight loss goals?

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Is your spouse, fiance, partner, or children overweight?

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If yes, who?

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How often do you eat out?

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Please describe in detail a typical day of food of food and drink for you?

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What is your main reason for wanting to lose weight?

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