Health History and Review of Systems (Please check all that apply)

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1 Health History and Review of Systems (Please check all that apply) Last Name: First Name: Date of Birth: / / q Male q Female Age: Marital Status: q Single q Married q Divorced q Separated q Widowed Who is your Primary Care Physician? Date of most recent physical exam: Date of most recent lab work: Check all conditions with which you have been diagnosed in the past (indicate date of diagnosis if indicated): Provider signature: _ Date: / / Page 3 of 7

2 Medications: Please list all medications (over the counter and prescribed) you are currently taking. Name of Medication Dosage Frequency Start Date Reason Notes (For provider use only) Vitamins and Supplements: Please list all vitamins, minerals and other over-the-counter supplements you are currently taking. Name of Supplement Dosage Frequency Start Date Reason Notes (For provider use only) Surgical History Surgical History (Please list all major and minor surgical procedures and operations excluding weight loss surgery.) Procedure Date Reasons Provider signature: _ Date: / / Page 4 of 7

3 Family History: Is this person living? Age at death Cause of death Father Mother Sibling Sibling Sibling Child Child Child Notes Please check all that apply: Father Mother Sibling Sibling Sibling Child Child Child Obesity Diabetes Heart Disease Hypertension High Cholesterol Stroke Depression/Anxiety Hypothyroidism Cancer (type?) Unknown History Social History Are you married? Ages of children: Spouse or children overweight? Who does the grocery shopping? Who does the majority of the cooking? Do you drink soda or sweet tea? Regular or Diet? How many per day? Smoking Alcohol Drug Abuse q Current q Past q Current q Past q Current q Past Packs per day Drinks per day Substance Provider signature: _ Date: / / Page 5 of 7

4 Weight History How many years have you been overweight? Approximate current weight: Goal weight: Highest weight (non-pregnant): Describe your weight gain: q Progressive q Sudden q Yo-Yo At what ages were you overweight? q Under 2 q 2-11 q q q q 60+ What factors have triggered weight gain for you in the past? q Stress q Depression q Medication- q Travel q Quit Smoking q Physical injury q Poor food choices q Pregnancy q Divorce q Social events/eating out q Excessive alcohol What is your reason for wanting to lose weight at this time? What, if any, barriers do you see as challenges to successful weight management? q Cost q Time commitment q Support of family or spouse q Unable to exercise q Chronic illness q Lack of understanding of nutrition q Other: Have you had weight loss surgery? (describe below) Weight Loss Surgery Type Date Surgeon Weight Loss / Gain q Loss lbs q Gain lbs Lowest weight after surgery: Please indicate which of the following Diet Programs you have attempted: Weight gained back since surgery: lbs Program Dates Supervised? Results Atkins (Low Carb) Diet q Loss lbs q Gain lbs South Beach q Loss lbs q Gain lbs Jenny Craig q Loss lbs q Gain lbs Nutri-System q Loss lbs q Gain lbs hcg q Loss lbs q Gain lbs Medifast q Loss lbs q Gain lbs Optifast q Loss lbs q Gain lbs Personal Physician q Loss lbs q Gain lbs Slim For Life q Loss lbs q Gain lbs Weight Watchers q Loss lbs q Gain lbs Medi-Weight Loss q Loss lbs q Gain lbs Other: q Loss lbs q Gain lbs Weight Loss Medication History: Medication Dates Used Successful? Results Phentermine (Adipex or generic) q Loss lbs q Gain lbs Phendimetrazine q Loss lbs q Gain lbs Diethylpropion (Tenuate) Qsymia q Loss lbs q Gain lbs Belviq q Loss lbs q Gain lbs Xenical (Orlistat) q Loss lbs q Gain lbs Other: q Loss lbs q Gain lbs Provider signature: _ Date: / / Page 6 of 7

5 Eating / Exercise Behaviors Are you currently on a diet? Please describe: Eating Behaviors: # of Meals / day: # of Snacks / day: What do you drink during the day? # of oz. / day: Describe your typical menu: Morning: Lunch/Midday: Dinner/Evening: Night: Any special dietary requirements or restrictions: How often do you eat out? q 1-5 meals / week q 6-10 meals / week q 10+ meals / week Check all behaviors that apply to you currently: q Late night snacking q Constantly snacking q Eating quickly q Frequently eating fast food q Large bites q Large portions Exercise: Are you currently exercising? Check all that apply: q Walking / Jogging q Pilates / Yoga q Strength Training q Swimming q Tennis q Biking q Aerobics / Elliptical q Other How often? How long? What keeps you from exercising? q Joint pain q Fatigue q Lack of time motivation q Other Provider signature: _ Date: / / Page 7 of 7

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