Weight History. General Patient Questions. Reason for Visit

Transcription

1 General Patient Questions Age Reason for Visit General History Alcoholism Yes Hepatitis A Yes Anemia Yes Hepatitis B or C Yes Arthritis Yes Hernia Yes Asthma Yes High blood pressure Yes Bleeding tendency Yes High thyroid Yes Blood clots Yes HIV / AIDS Yes Blood transfusion Yes Hives Yes Breast cancer Yes Illicit drug use Yes Bronchitis Yes Keloid formation Yes Cancer Yes Kidney disease Yes Colon cancer Yes Liver disease Yes COPD Yes Low thyroid Yes Deep vein thrombosis Yes Lung cancer Yes Depression Yes Lupus Yes Diabetes Yes Migraines Yes Dialysis Yes Mitral valve prolapse Yes Eczema Yes Pneumonia Yes Emphysema Yes Prostate cancer Yes Epilepsy Yes Seizure Yes Glaucoma Yes Stroke Yes Heart attack Yes Tuberculosis Yes Heart failure Yes Ulcer Yes Hemorrhoids Yes Comments Activity Level Fully active 0 Restricted in strenuous activity, able to do light work 1 Can walk, provide all self care, moves more than 50% while awake 2 Limited self care, confined to bed more than 50% while awake 3 Disabled, no self care, completely confined to bed or chair 4 Social History Alcohol use Yes Tobacco use Yes Recreational drug use Yes Type / Frequency / How long

2 Previous Hospitalizations Year Previous Surgery Year Active Medical Problems Onset Allergies Symptoms Family History Alive Medical Problems Mother Yes Father Yes Brother Yes Sister Yes Yes Yes Medications Reason

3 Review of Systems Endocrine Yes Do you have type 1 diabetes? Do you have type 2 diabetes? Have you been told that you have prediabetes? Do you have a history of hyperthyroidism (overactive thyroid)? Do you have history of hypothyroidism (underactive thyroid)? Have you or anyone in your family had medullary thyroid cancer? Do you have dry mouth? Do you have excessive urination? Do you have excessive thirst? Women Do you have increased facial hair? Do you have acne? Do you have irregular periods? Have you been diagnosed with infertility or been told you re infertile? Have you ever had a mammogram? When was the last time: Men Have you been diagnosed with low testosterone (low-t)? Do you have low sex drive? Have you been diagnosed with erectile dysfunction? Lung and Breathing Disorders Yes Do you have a history of asthma? Do you have a history of COPD (chronic obstructive pulmonary disease)? Do you snore? Have you been diagnosed with sleep apnea (severe snoring that interferes with your sleep)? Do you wheeze? Do you get short of breath when walking? Cardiac Yes Have you ever been diagnosed with angina? Have you ever had a heart attack? Have you ever been diagnosed with congestive heart failure (CHF)? Have you been diagnosed with heart valve disease? Do you get short of breath when laying down? Do your feet swell? Have you ever been diagnosed with an arrhythmia (irregular heart beat)? Have you ever been told you have a heart murmur? Do you take medication for high cholesterol? Do you take medication for high blood pressure? Do you ever have chest pain? Do you ever have palpitations (racing heart)?

4 Urinary Yes Do you have a history of kidney stones? Do you have trouble holding your urine, especially while walking running, coughing, or sneezing (urinary stress incontinence)? Do you experience excessive urination (urinate more than normal)? At night, do you wake up to urinate? Do you ever have blood in your urine? Eye Yes Do you have a history of glaucoma? Do you have diabetic retinopathy (diabetes-related eye disease)? Do you have blurry vision? Gastrointestinal Yes Have you ever been diagnosed with GERD (gastroesophageal reflux Do you ever have heartburn? Have you ever been diagnosed with liver disease? What type(s): Have you had gallstones? Have you had your gallbladder removed? Have you ever been diagnosed with pancreatitis? Gastrointestinal Yes Do you have abdominal pain? Have you had part of your intestine removed? Have you been diagnosed with gastroparesis? Do you frequently have diarrhea? Do you frequently have nausea? Do you vomit frequently? Psychiatric Yes Have you ever been diagnosed with depression? Have you ever been diagnosed with anxiety? Have you ever taken medication for depression or anxiety? Have you ever been diagnosed with ADHD (attention deficit hyperactivity disorder)? Have you ever been diagnosed with bipolar disorder? Do you have trouble sleeping? Do you have memory loss? Do you avoid social interaction because of your weight? Have you ever felt discriminated against because of your weight? Does being overweight cause you to feel depressed?

5 Do you drink more than 2 alcoholic beverages per day? Do you take pain medication or opiates on a regular basis? Oncology Yes Have you ever been diagnosed with cancer? What type(s): Obstetrics Yes Are you pregnant? Are you nursing? Are you planning to become pregnant within the next year? Have you ever had trouble getting pregnant or used fertility treatments? Neurologic Yes Have you ever had a seizure Have you ever had a stroke? Do you have tingling in your fingers or feet? Do you have a hand tremor, or does your hand shake when you hold it Have you ever had migraine headaches? Do you take medication to prevent migraines? Nephrology Yes Have you been diagnosed with chronic kidney disease (CKD) or diabetic nephropathy? Joint Diseases Yes Do you have a history of arthritis? Do you have pain in your knees? Do you have pain in your hips? Do you have chronic back pain? Do you have trouble walking or exercising due to joint pain? Do you take medication for joint or back pain? Have you had a joint replacement (e.g., hip or knee surgery)? Peripheral Vascular Diseases Yes Do you have pain or cramping in your legs after exertion? Do you have or have you had ulcers on your feet or legs?

6 Age Height Weight BMI (office staff) Waist Circumference Were you overweight as a child Age when you first became 20 pounds overweight Weight at high school graduation Weight on your wedding day Highest weight of your life Family History Overweight Mother Yes Father Yes Brother Yes Sister Yes Yes Bariatric Medical History Kidney problems Yes Prior ulcer in stomach or duodenum Yes Clotting problems Yes Hiatal hernia Yes Gastric surgery Yes Cancer Yes Liver surgery Yes Prior heart attack or stroke Yes Pancreatic surgery Yes Pain in legs when you walk Yes Splenic surgery Yes Ongoing abdominal pain Yes Prior abdominal radiation treatment Yes Inflammatory bowel disease Yes Prior abdominal embolization Yes Irritable bowel Yes Liver problems Yes Autoimmune disease Yes Cirrhosis Yes Allery to iodine or x-ray dye Yes Prior bleeding from stomach or bowels Yes Are you pregnant Yes Comments / tes

7 Weight Management History Have you ever been treated by a doctor for your weight? Yes When (year)? Were you successful? Yes How much weight did you lose? Have you ever consulted with a registered dietitian? Yes Have you ever participated in a weight loss program? Yes Please indicate which of the following weight loss programs that you have tried: Program Length of Time Weight Lost When? Weight Watchers Atkins / Low Carb Jenny Craig Nutri-System Medi-Fast Opti-fast HCG Pro-Cal Lindora HMR Other Have you ever taken medication to lose weight? (check all that apply) Medication Did you have side effects that Was it made you stop taking it? (If effective? so, list side effect) Phentermine (e.g., Adipex) Tenuate (diethylpropion) Belviq (lorcaserin) Contrave (naltrexone/ bupropion) Qsymia (phentermine/ topiramate) When did you take it? (List years)

8 Medication Saxenda (liraglutide for weight loss) Xenical (prescription orlistat) Alli (over the counter orlistat) Was it effective? Did you have side effects that made you stop taking it? (If so, list side effect) When did you take it? (List years) Topamax (topiramate) Glucophage (metformin) Victoza (liraglutide for type 2 diabetes) Meridia (sibutramine) Phen/Fen or fenfluramine Herbal: Other: Surgery Have you ever had bariatric surgery? Yes Are you currently considering bariatric surgery? Yes Have you ever consulted a surgeon regarding bariatric surgery? Yes Work What type of work do you do? Dietary Habits During the last 3 months, did you have any episodes of excessive overeating (i.e., eating significantly more than what most people would eat in a similar period of time)? Yes If yes, about how many times? Do you sometimes make yourself vomit as a means to control your weight? Yes Have you ever been diagnosed with (check all that apply): Binge eating disorder Anorexia nervosa Bulimia

9 Physical Activity Do you exercise regularly? Yes If yes, what kind of exercise? How many times per week? How many minutes per session? Social Support Does your family support your efforts to have a healthier lifestyle? Yes Do you see a counselor of any kind (e.g., therapist, religious leader, addiction counselor, psychologist, psychiatrist)? Yes Do you belong to any support groups (e.g., Weight Watchers, Overeaters Anonymous, Alcoholics Anonymous, Alanon, etc.)? Yes For Office Use Physical Examination Head M facies EOMI Skin Hirsuitism Acne Rash Acanthosis nigricans Neck Enlarged thyroid Thyroid bruit Carotid bruit Thyroid nodule Prominent supraclavicular fat pad Prominent dorsocervical fat pad Yes Yes Lungs Wheezes Crackles or rales Heart Tachycardia Murmur Abdomen Striae Heptomegaly Distension Extremities Edema Distal pulses palpable Nervous system Tremor Comments / tes