Medical, Gastro-Intestinal, Social Lifestyle Information Questionnaire TODAY S DATE: / / PATIENT NAME: Gender: M / F Age:
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1 Gender: M / F Age: Employment- ( PT / FT) Unemployed / Retired / Disabled / Occupation: Reason for visit: Race: PLEASE CHECK-OFF CAUCASIAN AFRICAN AMERICAN NATIVE AMERICAN MIDDLE EASTERN HISPANIC ASIAN OTHER WISH NOT TO ANSWER Primary Care Physician: Phone #: *** WEIGHT HISTORY Have you been overweight since Childhood? Yes/ No How many years have you been overweight?, at least 100 lbs overweight? Maximum Weight? When? / Minimum Weight?, When? Can you identify any changes that occurred which might have influenced your weight? (ex. Pregnancy, medications, stress ) WEIGHT LOSS METHOD/PROGRAM (WITHIN LAST 5yrs.) DATES: FROM- TO WEIGHT LOSS/ GAIN COMMENTS: Physician/ Dietitian Supervised Loss lbs. Gain lbs. Self-Imposed Dieting: Low fat, Soups, Juices, Describe: Loss lbs. Gain lbs. Organized Prgm: Circle Weight Watchers/ Jenny Craig / LA Weight Loss Loss lbs. Gain lbs. Exercise/Personal Trainers Loss lbs. Gain lbs. Medifast/Optifast Loss lbs. Gain lbs. Herbalife/Metabolife Loss lbs. Gain lbs. Atkins (low carb. diet) Loss lbs. Gain lbs. High Protein Liquid Diet/Shakes Loss lbs. Gain lbs. Prescription Medications: Circle Adipex/Redux/Phentermine/Xenical/Meridia Loss lbs. Gain lbs. Other: Describe Loss lbs. Gain lbs. 1 P a g e
2 ***Please list all past surgeries (description) : Year: ***Are you aware of any problems with anesthesia? YES / NO If yes, please explain below: Any previous problems with insertion of breathing tube for surgery? YES / NO Have you taken any steroids within the last six (6) months? YES / NO- Explain: Medication Allergies Reaction Medical Allergies: Latex (Gloves, Balloons, etc.) Surgical Tape I have NO medication allergies check Initials: Family Medical History: Medical Condition Family Member Medical Condition Family Member Diabetes Mellitus High Blood Pressure High Cholesterol Obesity Stroke Heart Disease Depression Alcoholism Thyroid Disorder Cancer Blood Disorder Kidney Disease Lung Disease Other (include family member): 2 P a g e
3 ***Patient: Please list all of your current medications and vitamins/supplements Medication Name Dose/Frequency Reason PHYSICIAN NOTES: Medical History- Have you, the patient, been diagnosed with any of the following: DISEASE YES NO DISEASE YES NO High Cholesterol High Blood Pressure Chest Pain Irregular Heart Rate Congestive Heart Failure High Triglycerides Heart Disease Heart Attack Murmur Mitral Valve Prolapse Have you ever had a Stress Test? Cardiac Catheterization (cath)? Diabetes- Type ( 1 ) Diabetes- Type ( 2 ) Thyroid Problems Obstructive Sleep Apnea COPD If yes, do you use a CPAP machine? Year Tested: Bronchitis Snoring Shortness of Breath with exertion Have you ever had a chest X-Ray? Daytime Fatigue Emphysema Shortness of Breath at rest? Difficulty Urinating Year Tested: Stress Incontinence Blood in Urine 3 P a g e
4 DISEASE YES NO DISEASE YES NO Kidney Failure Infertility Gender Reassignment Sexually Transmitted Disease History Of Cancer Anemia Sickle Cell Leukemia/Lymphoma Rashes Joint Pain Arthritis Chronic Back Pain Knee Pain Chronic Edema Rheumatoid Arthritis Osteoporosis Unplanned Weight Loss Chronic Sinusitis Hearing loss/ problems Dizziness Tension Headaches/ Chronic Headaches/ Migraines Seizures Glaucoma Fainting Spells Weakness/Paralysis Physical Problems Interfering with Lifestyle Bladder Infections Kidney Infections Kidney Stones HIV/ AIDS Cancer Type: Bleeding Problems Bruise Easily Moles, recent changes Leg Swelling Blood Clot Varicose Veins Hip Pain Ankle Pain/ Foot Pain Osteoarthritis Chronic Venous Insufficiency Gout Chills Sinus Headache Neuropathy Alzheimer s Disease Stroke Tremors Multiple Sclerosis Numbness Other: Other: PHYSICIAN NOTES: 4 P a g e
5 GASTRO-INTESTINAL HISTORY Heartburn Acid reflux/gerd Hoarseness Sore Throat Laryngitis Throat Clearing Difficulty Swallowing Feeling of something in throat Burping/Belching Bloating Regurgitation Vomiting Vomiting with Blood History of Ulcers Irritable Bowel Syndrome (IBS) Chron s Disease Diarrhea Black Stools (Bowels) Blood in stools (bright red blood) Constipation Diverticulitis Diverticulosis Teeth Sensitivity History of Barretts Esophagus Colon Polyps Difficulty Sleeping Secondary to GI symptoms Nocturnal Chocking Nocturnal Drooling PHYSICIAN NOTES: SOCIAL HISTORY Status: Single/ Married/ Separated/ Divorced/ Widowed -- Previously divorced: Yes/ No Do you use tobacco: Yes/ No - Currently smoke? Packs/day for years. Willing to quit? Yes / No --Quit smoking yrs. ago but previously, packs/day for yrs. Do you drink alcohol? Yes / No --- Daily / Weekly / Monthly / Socially Do you use recreational drugs? Yes / No --- Are you currently exercising regularly? Yes / No If exercising, what type of activity and how often? EMOTIONAL WELL BEING Have you ever seen a Psychiatrist/ Psychologist? Yes / No Currently? Yes / No Reason: Dual Personality Schizophrenia Nervous Breakdown Depression Eating Disorder Substance Abuse Anxiety Attacks 5 P a g e
6 CONTINUED: Is there any current depression? Yes / No ----Have you ever been admitted to a psychiatrist institution? Yes / No If yes, when? For how long? Reason: Have you ever been abused? Physically / Sexually/ Emotionally-- Received medical treatment and/or counseling? Yes / No Have you ever had an addiction? Yes / No --- Alcohol / Drugs / Other: If yes, have you received treatment? Yes / No Is the addiction current? Yes / No Have you considered suicide? Yes / No Do these feelings continue? Yes / No Have you ever attempted suicide? Yes / No --- If yes, when? Have you ever uncontrollably binged on a large amount of food at one time? Yes / No Have you ever intentionally vomited after eating in order to control weight? Yes / No Have you ever used laxatives in order to control weight? Yes / No Have you ever intentionally starved yourself in order to lose weight? Yes / No Have you ever hidden foods/food intake from others in your home? Yes / No Have you ever been medically diagnosed with an eating disorder? Yes / No When? Anorexia / Bulimia / Binge Eating/ Other: Do you feel you have an excess amount of daily stress? Yes / No If yes, from where? (Ex. Work, finances, family, etc)? Do you feel you have a helpful support system around you? Yes / No --Who? Please describe what you hope to accomplish and how you believe your life will change by losing weight: All of the information that I have submitted is accurate to the best of my knowledge. I understand that giving false or incomplete information can adversely affect my treatment and outcome. I accept any responsibility for such omissions and inaccuracies. Print Name Date Signature 6 P a g e
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