New Patient History Patient Name: Age: Date of Birth:

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Felicia Bennett
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1 New Patient History Patient Name: Age: Date of Birth: Is there a physician you would like us to send a letter about your visit/progress here? If yes, please provide their name, address & office phone number: I. MEDICATIONS Please list all medications, include over the counter medications and supplements. Drug Strength Frequency *if you require additional space, please feel free to use the back of this form Please indicate if you have ever or are still taking any of the following medications: Ever Used Still Using Category/Medication Corticosteroids (prednisonse, etc) Birth control pills Other hormones Beta blockers (metoprolol, carvedilol, etc) ACEi/ARB (Lisinopril, losartan, etc) Antidepressants (list which ones please) Lithium carbonate Diuretics (water pills) Oral diabetes medications (list past and present) Thyroid hormone Acid reflux medications (Pepcid, Protonix, etc) Antipsychotics (Zyprexa, Seroquel, etc) Opiate pain medications (hydrocodone, oxycodone, etc) Benzodiazepine anxiety medication (Ativan, Xanax, etc) Prior medications for weight loss (please list) Comments 1

2 II. MEDICAL PROBLEMS Please check if you have/had had the diagnosis, and provide further information if indicated o Hypertension Age at onset o Well controlled o Poorly controlled o Coronary Artery Disease Age at onset o Ongoing chest pain/angina o Prior heart attack (myocardial infarction) o Heart attack within last 3 months Cardiologist Name o Gout or Elevated uric acid level o Gallstones o Gallbladder removed o History of kidney stones o Were the stones documented as containing uric acid? o Arthritis Which joints predominately affected: o Diabetes Mellitus o History of diabetic ketoacidosis (DKA) Age at onset o Insulin dependent o On oral medications o Diabetic retinopathy o Neuropathy o Protein in your urine o Gestational diabetes history o High Cholesterol/Hyperlipidemia Age at onset o LDL elevated o Triglycerides elevated o Liver disease requiring protein restriction o Pregnant or planning to become pregnant within the next 6-12 months o Kidney disease requiring protein restriction o Current or prior treatment for cancer, if yes please describe o Stomach ulcer o Inflammatory bowel disease (Crohn s or Ulcerative Colitis) o Migraine headaches o Skin problems due to weight (breakdown in skinfolds, for example) Where Prior treatment for this o Other problems you attribute to your weight Date of most recent menstrual period: Number of pregnancies: Weight gain with pregnancies: Past Surgical History: III. ALLERGIES OR UNUSUAL REACTIONS Medication or Food Reaction 2

3 *if you require more space, please use the back of this page IV. DISABILITY Please rate each of the weight-related disabilities None Mild Moderate Severe (inconvenienced) (limited activity) (total) Respiratory (shortness of breath, low oxygen, sleep apnea) Cardiac (angina, heart failure, swelling, high blood pressure) Orthopedic (arthritis, tendon injury, back pain) Metabolic (diabetes, high cholesterol, gout) Functional (can t tie shoes, fit in chairs) Overall Comments, if any: V. WEIGHT Height: Present Weight: Goal Weight: When where you last at your goal weight? How much weight do you hope to lose? Indicate ages during which you were over a healthy weight: o Childhood (2-11 years) o Adolescence (12-19 years) o Age years o Age years o Over 40 years Which weight loss methods have you tried in the past? (e.g NutriSystem, Jenny Craig, Protein Formula, Medications, Starvation, Spa, Hypnosis, Weight Watchers, Psychotherapy, Etc) Weight loss method How long maintained Why stopped Problems during treatment Sample: Stillman diet 2 months Desired other foods Dizziness Which weight loss method did you consider most successful? What accounted for that success? 3

4 VI PSYCHOSOCIAL AND LIFESTYLE Are you at present undergoing any major lifestyle changes (eg marriage, divorce, job change, death of someone important to you)? If so, please describe: What other commitments do you have that might interfere with you fully participating in a weight loss program? What benefits do you hope to gain from being here other than losing weight? Who do you feel will be supportive of your weight loss and changes in lifestyle? (circle and name your choices) Spouse/significant other Children Roommate(s) Parent(s) Friend(s) Co-worker(s) Other Who do you feel may NOT be supportive of your weight loss and changes in lifestyle? (circle and name your choices) Spouse/significant other Children Roommate(s) Parent(s) Friend(s) Co-worker(s) Other Please list 5 reasons it is important for you to lose weight. Please make 1 your most important reason How did you hear about us? Why did you choose us? Are you currently or previously been in any kind of psychotherapy? With Whom? For What? When did you start? When did it end? Have you ever been hospitalized for psychiatric reasons? If so, please complete: Date of Admission Length of Stay Reason for Hospitalization Have you had recent suicidal thoughts? Have you been severely depressed? o Possibly Have you ever experienced dramatic mood changes during dieting (especially anxiety or depression)? o Possibly Have you ever eaten a large amount of food rapidly and felt this eating incident was excessive and out of control (aside from holiday feasts)? (circle one) Yes No If yes, how often did you do this during the past year? (check one) o Less than once a month o About once a month 4

5 o A few times a month o About once a week o About three times a week o Daily Have you ever purged (used self-induced vomiting, laxatives, or diuretics)? Do you drink alcohol? (circle one) Yes No If yes, how much? o 1 drink a month or less o 1 drink a week o More than 1 drink a week but less than 1 drink a day o 1 drink a day o More than 1 drink a day How often do you exercise? o Rarely or never o Occasionally o 1-2 times a week o 3-4 times a week o 5 or more times a week Has a doctor or other health care professional ever told you not to exercise? (circle one) Yes No Do you know of any reason why you should not exercise? (circle one) Yes No If yes to above, please explain: How many meals do you typically eat out per week? Are they usually fast food? Yes No Are the majority of these with family or friends? Yes No Usually in a cafeteria or restaurant? Yes No Check all the items that you feel help explain or describe your eating habits: Thinking about food too much of the time Eating high-fat foods Eating too many sweet foods/high sugar foods Eating too quickly Uncontrollable binges Eating in reaction to tension and depression Overeating when alone Using food as a reward Eating to take mind off other problems Not paying attention to what you are eating Overeating at social events Lack of satisfaction in life Eating in reaction to boredom Other (explain) Please circle any of the following products you are allergic to or sensitive to: Cocoa Milk Protein Corn Soy Eggs Aspartame (Nutrisweet) Monosodium glutamate (MSG) Lactose Other food allergies/sensitivities Do you smoke or use other tobacco products? Yes No If yes, how much? (eg 1 pack per day) Do you know or have you in the past used illegal drugs? Yes No If Yes, Which ones? Completed Rehab? Are you currently employed outside the home? Yes No On Disability Homemaker/Stay at home parent If Yes, what is your occupation? Highest Level of Education: What is your marital status? (e.g. single, divorced, married) 5

6 VII Family History Please indicate any diseases/illnesses that your parents, siblings or children have or have had. Or, indicate if you were adopted or otherwise unsure of your biological family history. Please include, if applicable, excess weight problems. Father o Alive Mother o Alive Brother(s) o Alive Sister(s) o Alive Children o Alive VIII PRIVACY Is there anyone, besides you, with whom you permit us to discuss your care? If so, please their contact information: I certify that the information on this form is true and correct to the best of my knowledge. Signature Date 6

Name (Last Name, First Name): SSN #: Date of Birth: Age: Sex: M F Other. Address: Home phone: Work phone: Cell phone:

SCREENING APPLICATION NOTE: THIS APPLICATION MUST BE COMPLETED BEFORE YOU CAN ENROLL IN THE NEW DIRECTION (ND) SYSTEM. PLEASE ANSWER EVERY QUESTION. PLEASE PRINT CLEARLY. Date: Name (Last Name, First Name):_