LEAF Weight Management Clinic Patient History Questionnaire
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1 LEAF Weight Management Clinic Patient History Questionnaire Instructions: Please bring the completed form with you to your first appointment at LEAF. For privacy, please do not mark your name on this form. This form takes about approximately minutes to fill. Section I: Weight History 1) Current weight? lbs Heaviest weight? lbs Lowest weight? lbs What age? What age? For women: this would be nonpregnant weight (maintained for at least 1 year since age 20) 2) Birthweight? lbs I don t know Where you born premature? Yes No I don t know 3) Which statement best describes your weight in childhood? I was overweight through most or part of my childhood. I was mildly overweight or chubby through most or part of my childhood. I was thin or normal weight throughout childhood. 4) Which statement best describes your weight at puberty? I continued to be overweight throughout puberty. I became overweight for the first time at puberty. I lost weight to normal at puberty. I was at normal weight at puberty. Puberty for men means the year your voice changed and had a growth spurt. 5) WOMEN: How old were you when menstruation (periods) started? years old MEN: How old were you when your voice changed and had a major growth spurt? years old 6) Which years of age have you been overweight? (Check all that apply) younger than 8 years older than 71 Version Jan 2016 Page 1
2 7) Can you date the onset of your weight problem to a specific year? Yes No If yes, what age were you then? years old 8) Do you connect your weight problem to a specific life event? Yes No If yes, what was it? 9) Do you have a desired weight? Yes No If yes, what weight do you hope to achieve? lb Section II: Lifestyle 1) Over the last 6 months have you been prevented from exercising because of your health? No Yes; If yes, please check all factors that prevent you from exercising: Overweight Arthritis, joint pain Limb amputation Fracture/sprain Hemi/Quadriplegia Lack of interest Heart problems Asthma Dislike Other: 2) Daily Energy Expenditure Fill the average number of hours spent on respected activity levels considering the example activities below. Decimal values are allowed (e.g. 2.5, 0.25). The total must equal 24 hours. Hrs Hrs Hrs Hrs Hrs Resting: Sleeping, reclining Very light: Seated and standing activities, painting trades, driving, laboratory work, typing, sewing, ironing, cooking, playing cards, playing a musical instrument Light: Walking on a level surface at 2.5 to 3 mph, garage work, electrical trades, carpentry, restaurant trades, house cleaning, child care, golf, sailing, table tennis Moderate: Walking 3.5 to 4 mph, weeding and hoeing, carrying a load, cycling, skiing, tennis, dancing, weight training including rest between sets. Heavy: Walking with load uphill, tree felling, heavy manual digging, basketball, climbing, football, soccer Version Jan 2016 Page 2
3 3) Current Physical Activity / Weekly Exercise Routine: DAY ACTIVITY TIME / DURATION MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Version Jan 2016 Page 3
4 4) Schedule: Please provide your typical weekly, work and social schedule Monday Tuesday Wed Thursday Friday Saturday Sunday Wake Time Work Hours Other activities (meetings, social engagements, etc) Bed Time 5) Smoking history: What statement best describes your smoking history? I have never smoked. (If you have never smoked go to question 6) I smoke (If so, how many cigarettes per day?) I quit smoking. (If so, how many years ago?) How many times during your life have you stopped smoking for more than 4 weeks? For how many years have you smoked? On average, how many cigarettes per day have you smoked over this time? 6) In the last 6 months, have you used recreational drugs? Yes No (Cannabis, marijuana, grass, hash, cocaine, etc.) Version Jan 2016 Page 4
5 7) In the last 6 months, please describe your alcohol intake. I am a non-drinker? Yes No I drink alcohol most weeks? Yes No I drink alcohol only on holidays and specific occasions? Yes No I drink in binges? Yes No If yes: How many days do the binges last? How many times per year do they occur? I have had a problem with alcohol in the past and now drink very little or nothing? Yes No If yes: How long have you been alcohol free? years months 8) In the average week over the last 6 months, please estimate how much of each of the following would you use: Beer (a 12 oz/360ml portion) Wine (a 5 oz/150ml portion) Spirits (Scotch, Gin Rum etc.) (a 1.5 oz/45ml portion) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Version Jan 2016 Page 5
6 9) Eating Pattern : Please fill out a typical day of eating: Breakfast Time: Lunch Time: Supper Time: AM snack Time: Afternoon snack Time : Evening snack Time: Is there a particular time of day that you find challenging for eating? No Yes If yes, when? And why? Counting all meals and any snacks you may have, how many times a day do you eat: Thinking about your usual or normal week, how many days out of the 7-day week do you: Eat breakfast: Eat brunch/lunch: Eat dinner: In a usual or normal week, please fill out how many days a week do you eat out at a fast food restaurant or other type of restaurant: Fast food restaurants Other types of restaurants Breakfast Brunch/Lunch Dinner days/wk days/wk days/wk days/wk days/wk days/wk Version Jan 2016 Page 6
7 Please fill out how much you drink of: Water: none cups per day: or cups per week: Caffeinated coffee: none cups per day: or cups per week: Decaf coffee: none cups per day: or cups per week: Caffeinated tea: none cups per day: or cups per week: Decaf tea: none cups per day: or cups per week: Regular pop: none cups per day: or cups per week: Diet pop: none cups per day: or cups per week: Juice: none cups per day: or cups per week: Milk: none cups per day: or cups per week: 10 Do you consider yourself an emotional eater? Yes No 11 Have you ever had a diagnosis of: Anorexia Nervosa? Yes No Bulemia? Yes No Binge Eating Disorder? Yes No 12 Have you ever been referred to an Eating Disorder Clinic? Yes No 13 Have you ever made yourself vomit after overeating? Yes No 14 Do you have times when you binge? Yes No (If no, skip to question 14) A binge is a large amount of food eaten in a short short time (usually less than 2 hours)and usually outside of regular meal times If Yes, which of the following might cause you to binge (check all that apply): No particular reason Boredom Sadness/depression Anger Relationship issues Hunger Parenting difficulties Stress After you binge, do you have feelings of self-criticism, depression or guilt? Yes No Over the last 6 months, how often would you binge: Never every day Once a week More than once a week Several times a month Occasionally Premenstrual week only Version Jan 2016 Page 7
8 Part III: Prior weight management strategies: 1) Have you ever taken medications for weight loss? No (skip to question 2) Yes If Yes, please check all medications that apply: Xenical Meridia Victoza Saxenda Fen-Phen Ionamine Other: 2) Have you ever had surgery for weight loss? 3) No (skip to question 3) Yes If Yes, please check what type of surgery: Lap-band gastric sleeve Duodenal switch Roux-en-Y gastric bypass Vertical banded gastroplasty (stomach stapling) Biliopancreatic diversion I had bariatric surgery but cannot recall what kind Please complete this table on types of weight loss programs you have tried. Include the year, number of months in the program, pounds lost and how long the weight was kept off. If you answered yes to Question 1 or 2, please include these answers in this table. Program Year Number of Months Weight loss in lbs How long did you keep the weight off? Here are some examples of programs: Weight Watchers, TOPS, medically supervised programs, Overeaters Anonymous, Registered Dietitian, or self-directed (South Beach, Atkins, GI Diet, etc) Version Jan 2016 Page 8
9 Part IV: Medical Conditions 1) In the last year, have you had? (Check all that apply) low back pain painful feet knee pain hip pain shortness of breath heartburn or hyperacidity stress incontinence (women) 2) Have you ever been told you have any of the following conditions? If Yes, when did you find out? Month & Year High blood pressure No Yes Cholesterol abnormalities No Yes High blood sugar or diabetes No Yes Fatty liver No Yes Thyroid problems No Yes Heart attack/angina/coronary artery disease No Yes Stroke/TIA No Yes Have you ever been hospitalized for a heart attack or angina or stroke/tia? No Yes Deep vein thrombosis (DVT)/ pulmonary embolism No Yes Gout or high uric acid No Yes Hepatitis (Hep C, chronic active hepatitis, etc. ) No Yes Inflammatory Bowel Disease (Crohns or Ulcerative Colitis) No Yes Irritable bowel syndrome No Yes Gallstones No Yes Version Jan 2016 Page 9
10 Have you had your gallbladder removed? No Yes Kidney stones No Yes Sleep apnea No Yes If Yes, are you presently using a CPAP machine for sleep apnea No Yes 3) The following questions are related to sleepiness: Are you likely to fall asleep during meetings? Are you likely to fall asleep while watching TV? Are you likely to fall asleep while waiting for a traffic light? No Yes No Yes No Yes Have people ever complained about your snoring? Has your partner ever expressed concern that you stop breathing during your sleep? No Yes Unknown* No Yes Unknown* *If there is no one available to observe your sleep. 5) Do you have any other medical conditions or ongoing treatments at this time? 6) Please list any hospital admissions you have had and the last year it happened: Reason for admission: Year: Version Jan 2016 Page 10
11 Part V: Medications, Vitamins, Supplements, Allergies Prescription Medication Name Dose Number of times taken DAILY or as needed Number of times taken MONTHLY OR List over-the-counter medications, supplements, or herbal preparations: Allergies to medications: Allergies or intolerances to food or environment: Part VI: Family History 1) Were you adopted? Yes No If Yes, and you do not know about your biological relatives, go to Part VII. 2) For first degree relatives (parents, siblings, children) is there a history of weight issues? Yes No If Yes, who struggled with weight? 3) Have first degree relatives (parents, siblings, children) had any of the following health conditions? (females before age 65 or males before age 55) Diabetes (adult onset) Angina Heart attack Stroke Version Jan 2016 Page 11
12 Part VII: For Women Only 1) Last menstrual period Year/Month Unsure 2) Date of menopause Year/Month Unsure 3) Last pelvic exam Year/Month Unsure None 4) Last pap smear Year/Month Unsure None 5) Last breast exam Year/Month Unsure None 6) Last mammogram Year/Month Unsure None 7) Are you on oral contraceptives? Yes No 8) Are you on hormone replacement therapy? Yes No 9) If you are having menstrual periods: Are they regular? Yes No Are they regular because of medications? Yes No If yes, please list which medications: 10) If your menstrual periods have stopped: Was it due to menopause? Yes No Was it due to hysterectomy? Yes No Was it some other reason? Yes: 11) Please list the number of full term pregnancies and their effect on your weight: Did you have gestational diabetes during pregnancy? Yes No Are you currently pregnant? Yes No Did your weight normalize after Pregnancy Year this pregnancy? #1 Yes No #2 Yes No #3 Yes No #4 Yes No #5 Yes No If yes, for how long did it stay normal (in months)? Thank you! Please bring to your medical appointment. Version Jan 2016 Page 12
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PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
Record-Keeping Charts
In this appendix, we have provided some useful charts for you so you can record information that s important to manage your diabetes. Use these charts to keep track of the information not only for yourself,
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely Date: email address: First name: Middle: Last: Nickname: Ethnicity/Race (please circle): Black or African American Caucasian Hispanic
Telephone: Fax:
PATIENT AUTHORIZATION TO RELEASE MEDICAL RECORDS AND DEMOGRAPHIC INFORMATION DATE: SS #: PATIENT NAME: BIRTHDATE: / / PATIENT ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE #: CELL PHONE #: REFERRING PHYSICIAN
Patient History Form: Bariatric Surgery Page 1 of 9
Date you attended Informational Session / / How did you hear about us? Radio Newspaper TV Word of Mouth Magazine Referred by Dr. Other: Name: Age: Date of Birth: / / Occupation: Gender: Male/Female Address:
MEDICAL WEIGHT LOSS PROGRAM. Medical History Form
MEDICAL WEIGHT LOSS PROGRAM 300 Gatewood Avenue, High Point, NC 27262 Phone: 336-905-6390 Fax: 336-905-6391 http://www.highpointregional.com Medical History Form Please Print: Patient Name: Date of Birth:
Legacy Weight and Diabetes Institute
General Information (Please Print Clearly) Email Address: Last Name Legal First Name M.I. Home Phone Address City State Zip Work Phone Social Security Number - - Sex Male Legacy Weight and Diabetes Institute
University of South Alabama Center for Weight Loss Surgery
Please bring this form to your fi rst appointment at the USA Center for Surgical Weight Loss University of South Alabama Center for Weight Loss Surgery For Offi ce Use Only: USASWL DEMOGRAPHIC FORM MRN
Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months? I don t know
What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy Monticello Have you had labs (lipid profile & basic metabolic panel) done within
Byers Wellness Center- Patient Information for HCG Program. General Patient Information
1 Byers Wellness Center- Patient Information for HCG Program Welcome to Byers Wellness Center. We are excited to have you as one of our patients. In order for us to best serve you on your initial visit
Centra Weight Loss Clinic Initial Appointment Questionnaire
*Please note: To provide appropriate care, forms MUST be completed prior to your initial visit. Name Date of Birth Physician Information Referring Physician / PCP (Name) Location (city, state) Date of
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
Weight 1 year ago (lb):
Health Profile Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client s health status in order to guide his
Here are some types of gastric bypass surgery:
Gastric Bypass- Definition By Mayo Clinic staff Weight-loss (bariatric) surgeries change your digestive system, often limiting the amount of food you can eat. These surgeries help you lose weight and can
Medical Nutrition Therapy Assessment For Adolescents Ages years old
Name: Birth Date: Today s Date: Medical Nutrition Therapy Assessment For Adolescents Ages 13-17 years old Please help us provide better care to you by answering all questions to the best of your ability.
Bariatric Patient Registration / /
Page 1 of 7 Bariatric Patient Registration / / Today s Date Please Print Clearly Patient s First Name Middle last Current Height / Weight Mailing Address City State Zip Home Phone Work Phone Cell /Pager
Sentara Surgery Specialists
Weight Loss Surgery Follow-Up Data Height Weight LB WL BMI EBW %EWL How many meals per day do you eat? On average, how long does it take you to eat a meal? How many times a day do you snack? How many 8
The Johns Hopkins Diabetes Center JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT. Name: Marital Status: M S W SEP D
JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT Date: JHH # I. General Information Name: Marital Status: M S W SEP D Address: Phone: Home: Work: Email: Fax: Sex: M F Date of
SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:
q JHMCE q JHS q SMEH SLEEP QUESTIONNAIRE 1. DEMOGRAPHIC DATA Name: Home Telephone Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: 2. PHYSICIAN INFORMATION Name of Primary
Lifestyle & Pre-diabetes Questionnaire
Please complete this questionnaire. The time you take to provide this information will help your health care team work better for you. General, Medical and Health Information Date: Name: Age: Race: Current
**Medicare and Medicaid have other Billing Codes and different eligibility. Please contact our office for more information. Thank you!
Checking Your Insurance Benefits IMPORTANT Please check your insurance coverage prior to any Nutrition or Diabetes Education appointment. You will be responsible for any services that are not covered.