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1 Patient Information PLEASE PRINT LEGIBLY Patients Name: Date of Birth: Sex: Patients Address: City: State: Zip: Home Phone: Cell: Work: SSN: Employer: Occupation: Marital Status: Employed: Full Time Part Time Retired Emergency Contact: Contact Number: Pharmacy: Phone: Primary Care Physican: Contact Number: Signature of Patient/Guardian: Date:

2 Patients Name: Personal Medical History: Do you have or have you ever had Check all that apply. Cardiovascular Urinary Heart Disease Difficulty with urination? MI (Heart Attack) Frequent bladder infections? Abnormal EKG Incontinence High Blood Pressure Constipation Respiratory Asthma Kidney Infections Gynecological Shortness of breath? Still having menstraul cycle? How far can you walk before getting short of breath? Duration: Is it getting worse? Regular: Date: Sleep Disorder Sleep Apnea Do you use a C-PAP? Psychological Depression Panic Attacks Anxiety Bi-polar Disease Obsessive Compulive Disease Anorexia Bulimia Binge Eathing Disorder Neurological Headaches Medications: Endocrine Diabetic Average daily blood sugars: Do you have a thyroid problem? Elevated Cholesterol Polio Jaundice Kidneys Lung Disease Rheumatic Fever Ulcers Anemia Gout Cancer Arthritis Measles Mumps Scarlet Fever Whooping Cough Bleeding Disorder Tuberculosis Pneumonia Heart Valve Disorder Gallbladder Disorder Eating Disorder Malaria Osteoporosis Tonsillitis Nervous Breakdown Pain Associated: Date of Last Menstrual Period: Pregnancies Number: Natural or C-Section: Are you taking hormones/birth control/ HRT? Date of last check up: Musculoskeletal Back Pain Hip Pain Knee Pain Swelling of Feet Ankle/Foot Pain Other Glaucoma Antibiotic resistant organisms Hepatitis Drug Dependency Alcohol Dependency Past Medical History: Check all that apply Pleurisy Liver disease Chicken Pox Thyroid Disease Heart Disease Psychiatric Illness Alcohol Abuse Typhoid Fever Blood Transfusion

3 Patients Name: Date: General: Cardiovascular: Gastrointestional: Yes No Yes No Yes No Fatigue Calf Cramps Abdominal Weight Gain Chest Pain Bloating Weight Loss Difficulty Breathing Lying Down Black, Tarry Stool Eyes/Ears/Nose/Throat/Mouth: Yes No Headache Blurred Vision Eye Pain Hearing Loss Glaucoma Neck: Neck Mass Swollen Glands Respiratory: Chronic cough Difficulty Breathing Snoring Wheezing Immunologic: HIV / AIDS Hepatitis (A,B, or C) Review of Symptoms: Have you ever had any of the conditions below? If so, please check ALL applicable boxes below Elevated Blood Pressure Bloody Stool Fainting Constipation Heart Attack Hemorhoids Irregular Heart Beat Heartburn Leg Pain / Swelling Nausea Palpitations Rapid Heart Rate Physchiatric: Date of Occurance: Yes No Varicose Veins Anxiety/ Panic Attacks Depression Musculoskeletal: Hallucinations Back Ache Insomnia Joint Pain Joint Swelling Neurological: Leg Cramps Decreased Memory Muscle Cramps Numbness Muscle Weakness Headaches Swelling to Extremities Seizures Stroke Endocrine: Visual changes Appetite Changes Weakness Excessive Thirst Excessive Urination Heat Intolerance Thyroid Problem

4 Allergies: Are you allergic to any medications? YES or NO If so, please list mediation and reaction Medicaton Reaction Prescription Medication: Medication Name Dose Frequency Non-Prescription Medication Medication Name Dose Frequency

5 Dieting History: Age you first started dieting: Approximate weight at 18 yrs Current Height: Current Weight Goal Weight: Weight Range last 5 yrs: to Max Weight Program Yes No Dates Duration Loss Jenny Craig Nutri-System Weight Watchers Opti-fast / Medi Fast O.A or TOPS Fen/Phen Meridia Xenical Over the counter Diet Aids Atkinds Diet South Beach Diet What was the most successful wiegth loss you have achieved and how did you do it? MD Supervised? Y or N What behaviors did you learn from dieting that you still use today?

6 Food Preference: Are you a sweet eater? Are you a bread/pasta eater? Do you eat fast food? Do you snak between meals? Is snacking from habit? Yes or No Boredom? Yes or No Do you binge eat? Yes or No What beverages do you consume throughout the day and qty? Social / Family History: Is there obesity in your family? Yes or NO Who? Have you been overweight all your life? Yes or NO If not, how long? Do you exercise regularly? Yes or NO How often? Any problems with exercise? Any previous prescription weight loss medication? What would your like your weight to be? At what age were you last at this weight? Have you been or are you being treated for alcohol or other substance abuse / dependence? Do you drink alcohol? Yes or NO How many drinks / week? Do you smoke? Yes or NO How many packs? Any family history of the following: Heart Disease Yes or NO Who? Stroke Yes or NO Who? Diabeties Yes or NO Who? Cancer Yes or NO Who? High Choleserol Yes or NO Who? Obesity Yes or NO Who? Glaucoma Yes or NO Who? Asthma Yes or NO Who? Epilepsy Yes or NO Who? High Blood Pressure Yes or NO Who? Kidney Disease Yes or NO Who? Psychiatric Disorder Yes or NO Who? Sudden Death Yes or NO Who? Please list any other serious illnesses you have had: Illness Date Treatment

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