Patient History Questionnaire. Nurse Consult Measurement
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- Barry Jacobs
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1 Patient History Questionnaire The information that is requested in this questionnaire is very important. To give you the best care, and to obtain your insurance approval, we must have complete answers. Please be thorough. Blue or black ink only, please. Name: Age: Sex: Occupation: (If retired, what did you do?) Actual Body Weight Your Measurement Nurse Consult Measurement Pre op Measurement Height Ideal Body Weight Excess Body Weight Target Weight What is your frame size? Small Medium Large Bust: Weight: Hips: Weight History Please estimate as closely as possible for all that apply: Birth Weight lbs. oz. Life Event Age Weight Beginning of High School High School Graduation Marriage Lowest Weight in the Past 5 yrs. Highest Weight in Past 5 yrs.
2 In your own words, please describe what you hope to accomplish and how you believe your life will change by losing weight?
3 Past Medical History Please identify which of the following childhood illnesses you have experienced. Measles Mumps Chickenpox Obesity Rheumatic Fever Heart Murmur Asthma Tonsillectomy Female Patients: No. of pregnancies: Age of first period: No. of live births: Date of last period: Miscarriages / Abortions: Obstetric complications: Do you presently use any of the following: Birth Control Pills Yes No List Type: Estrogens Yes No List Type: Other contraceptive method: Serious Illnesses Have you had any of the following: Hepatitis Blood Transfusion AIDS / HIV Exposure Colitis Kidney Disease Bleeding Abnormality Thyroid Problems: Please list below all serious illnesses and hospitalizations you have experienced in adulthood. Major Illnesses Date Treatment Major Surgeries Date
4 Allergies Are you allergic to any medications Yes No If yes, please list medication and reaction: Medication Reaction Are you allergic to: Surgical Tape Yes No Latex Yes No Iodine Yes No Any other allergies: Medications Please list below all medications you are currently taken (including over the counter medications) If not enough space to list please use a separate sheet of paper. Medication Dose (mg) / Frequency (how often) / and Reason Do you smoke or use tobacco? Yes No How often? Are you willing to quit? Yes No Do you use alcohol? Yes No How often? Family History Family Members Living Age If deceased, age Illness / Cause of Death Mother Father
5 Maternal Grandmother Maternal Grandfather Fraternal Grandmother Fraternal Grandfather Sibling Sibling Please indicate if you have a family history of: Obesity Lung Disease, Asthma/Emphysema Colon Cancer Diabetes Kidney Disease High Cholesterol High Blood Pressure Heart Disease Breast Cancer Bleeding tendency or Blood Disorder
6 System Review Please circle all symptoms you currently experience or have experienced in the past. Feel free to add any additional problems or information. HEAD, EYE, EAR, NOSE & THROAT: stuffy nose runny nose hay fever sinus trouble ear ache headache blurry vision double vision haloes around lights loss of night vision buzzing in ears ringing in ears discharge from ears loss of hearing dizziness vertigo loss of balance sore throat lump in throat trouble swallowing pain with swallowing hoarseness. RESPIRATORY: cough wheeze shortness of breath at night use of two pillows blood in sputum out of breath with exertion wake up at night short of breath wake up at night coughing or choking asthma emphysema bronchitis. CARDIOVASCULAR: palpations pounding heart skipping heartbeat pains in chest pains in neck pains in arms squeezing of chest heart attack heart murmur abnormal EKG irregular heartbeat high blood pressure pain in legs cold feet blue toes blue fingers loss of pulse/ GASTROINTESTINAL: heartburn nausea vomiting belching fluid in throat burning in throat food sticking in chest pains in stomach burning in stomach acid stomach diarrhea constipation pain with bowel movement blood in stools hemorrhoids fissures cramps gassiness irritable colon colitis. GENITOURINARY: pain with urination trouble starting urine trouble stopping urine small urine stream blood in urine kidney stones bladder stones kidney failure nephritis urinary tract infections frequent urination getting up at night to urinate leakage of urine when coughing or sneezing. Men: discharge from penis loss of erection painful erection. Females: vaginal discharge vaginal bleeding pain with intercourse irregular periods. ENDOCRINE (GLANDULAR): hypothyroid hyperthyroid goiter Grave s disease thyroid nodules diabetes adrenal gland tumor frequent flushing frequent heavy sweating. MUSCULOSKELETAL: pain in joints swelling of joints redness of skin over joints warm joints fluid in joints arthritis broken bones sprains low back pain hip pain knee pain ankle pain foot pain flat feet slipped disk herniated disk sciatica. NEUROLOGICAL: dizziness vertigo falling to the side falling at night numbness tingling pins and needles sensation weakness of any muscles twitching of muscles weakness of grip shakiness tremors fainting convulsions fit loss of consciousness.
7 PSYCHOLOGICAL: nervousness anxiety depression thoughts of suicide suicide attempts hospitalization for emotional problems psychiatric treatment psychological counseling.
8 List of Medications Medication Dose (mg)/ Frequency (how often)/ and Reason
9 Dietary History Approximate age when you first seriously dieted? List the diets and diet programs that you have tried: Programs Yes No Dates Duration MD Supervised? Max. Wt. Loss Jenny Craig Nutri Systems Weight Watchers Optifast Medi Fast Fen/Phen/Redux Meridia Lindora T.O.P.S O.A Acupuncture Metabolife Atkins Diet Pritikin Diet List any physician supervised and documented weight loss attempts: List any other diets and/or weight loss methods you ve tried:
10 For Female Patients only: Pregnancy # Year Weight at start Weight at delivery Food Preferences Please indicate which foods would most likely make you go off the diet. Rank each selection from 1 = like very much to 4 = don t care soda/ soft drink French fries chips/snacks chocolate steaks/ chops candy potatoes pasta cookies pizza cakes/ pies salad dressing
11 Weight Related Illnesses Have you had, or do you have, any of the following illnesses or symptoms? 1) Heart Disease Yes No If yes, year diagnosed? Do you have, or have you had? Angina M.I. (myocardial infarction) CABG (coronary artery bypass graft) Abnormal EKG Stress test to rule out cardiac problems Palpations 2) High Cholesterol Yes No High Triglycerides Yes No If yes, year diagnosed: List Medications: 3) High Blood Pressure Yes No If yes, year diagnosed: List medications: 4) Diabetes Yes No If yes, year diagnosed: Gestational? Neuropathy? Controlled with: Diet Oral Medication List medication and mg: Insulin List medication and doses: Last fasting blood sugar: 5) Asthma Yes No If yes, year diagnosed: Number of ER visits in the last 2 yrs. Number of hospitalizations in the last 2 yrs. Any steroids in the last 2 yrs. Yes No 6) Shortness of Breath Yes No If yes, you can walk blocks If yes, you can climb flight of stairs 7) Trouble Sleeping Yes No Morning headache? Daytime drowsiness? Restless sleep? Snoring? Awakenings at night? Observed apnea?
12 8) Sleep Apnea Syndrome Yes No If yes, year diagnosed: Last sleep study: Do you use CPAP? 9) Heartburn/ esophagitis/ hiatal hernia Yes No If yes, year diagnosed: Have you had an Upper GI series? Yes No Yes No Have you had an Endoscopy? List medication: 10) Belching up acid or sour fluid Yes No 11) Coughing or choking at night Yes No 12) Gallbladder Disease Yes No If yes, year diagnosed? 13) Leakage of urine with laughing/ coughing/ sneezing Yes No If yes, do you wear pads frequently? 14) Low back strain/ pain/ sciatica Yes No If yes, are seen by a chiropractor? Orthopedic Surgeon? Family Doctor? List medication: 15) Pain in hips/ knees/ ankles/ feet Yes No If yes, are seen by a chiropractor? Orthopedic Surgeon? Family Doctor? 16) Weight related injuries and traumas 17) Venous stasis disease Yes No Edema Scaly and thick skin Leg ulcers Varicose Veins 18) Gout Yes No If yes, gouty arthritis? List medications: 19) (Females Only) Bra Size? Skin depressions from bra straps Yes No Do you have shoulder pain? Yes No
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