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medical & diet history form

Please bring 5 years of weight history from your PCP to your first appointment.

  First Name: *
  Last Name: *
  Address: *
  City: *
  State: *
  Zip: *
 
  Phone: *
     
 
1. Diet History-  
  How long have you been 75-100 pounds overweight?
  Were you over weight as a child?
Yes No
 
Name of Diet
(if a physician monitored the diet please list the doctors name)
Date
Weight
Loss/Gain

Diet pills over the counter:

Diet pills prescription:

Diet Shots(HCG,B-12,Diuretics):

Weight Watchers:
Overeaters Anonymous:
Nutri-Systems:
Opti-fast, Medi-fast, liquid protein:
Hypnosis:
Richard Simmons:
Susan Powter:
Dr. Stillman/ Dr. Atkins:
Antidepressants:
Acupuncture:
Gastric Surgery:
Therapy/Counseling:
Nutritionist:
In/Out Patient treatment:
Other:
Describe:
 
2. Physical History:  
 

Do you or have you ever experienced the following conditions?
Diabetes
High Blood Pressure
Cardiac Problems ( palpitations, pain, heaviness in chest )
  Please explain

Blood clots ( due to injury or surgery )
  Please explain

Hepatitis B or C
Asthma or Chronic Bronchitis
Arthritis
Sleep Apnea ( c pap, or bi pap )
  Please explain

Shortness of breath upon exertion
Chemical dependency
Anorexia
Bulimia
Circulatory problems ( swelling, tingling, numbness )
  Please explain

Back pain
Reflux ( heartburn, indigestion ) (physician diagnosed)
Frequent headaches
Skin conditions ( Psoriasis, Yeast, Boils, Excema )
Depression
Bladder Incontinence
Irregular or painful menses
Elevated cholesterol or triglycerides
Infertility
Gout
Pain in weight bearing joints
  Please list joints

Colitis
Irritable bowel syndrome
  Please explain

 
3. Current Medications:  
 
Medication Name
Dosage
Taken For
 
4. Are you allergic to any medications?
 
Medication Name
Reaction
 
5 Significant Family History:
List any family members who have suffered or experienced any of the following conditions ( please list if maternal or paternal ) :
 
Hypertension
Diabetes
Arthritis
Cardiac Disease
Stroke
Lung Disease
Cancer ( kind )
Obesity
Liver Disease
Early Death Cause
All living siblings
All deceased siblings
   
Mother's Current Age or Age at Death (If deceased, age at death)
If deceased, cause of death
   
Father's Current Age or Age at Death (If deceased, age at death)
If deceased, cause of death
 
6. Surgeries and Hospital Admissions:
 
Date
Reason
 
7. General History:  
  Do you smoke?
Yes No
Do you drink alcohol?
Yes No
Do you use drugs?
Yes No
Do you use contraception?
Yes No
Are you allergic to any foods ( dairy, wheat products, shellfish…)?
Yes No
  Please explain

Are you allergic to any materials ( latex, iodine, surgical tape, wool….)?
Yes No
  Please explain
 
8. Physical
  Date of last physical:
  Results of physical:
 
9. Primary Care Physician
  Physician Name
  Physician Office Address
  Physician Phone Number
 
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