Now is the time for a trimmer, healthier you.

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2 Weight No More! Now is the time for a trimmer, healthier you. Medical Director: Peter Ruggiero, M.D Bariatric Physical Exam Name: Age: Date: Vital Signs: BP (sitting) Pulse Height (w/o shoes) inches Weight (w/o shoes) lbs. Preliminary Goal Weight B.M.I. Waist Circumference Hip Circumference Body Composition Analysis Completed and Review [ ] % fat W/H Ratio Frame/Shape Body Composition Analysis Completed and Review [ ] % fat % lean ECG Completed and Reviewed [ ] [ ] Normal [ ] Abnormal Medical History Review of Systems: Please Circle 1. Are you in good health at the present time? Yes No 2. Are you under a doctor s care? Yes No If yes, for what? Who is your primary care physician? 3. Are you taking any medications at the present time? Yes No If yes please list all mediations and dosages: 4. Are you allergic or sensitive to any medications? Yes No If yes please list those medications here. 5. History of High Blood Pressure? Yes No 6. History of Diabetes? Yes No At what age: 7. History of Heart Attack or Chest Pain? Yes No Please provide detail of heart attach and any intervention (e.g. by-pass surgery, angioplasty, stent placement)

3 8. History of thyroid disease or abnormalities? Yes No 9. History of frequent headaches or migraines? Yes No 10. History of constipation (difficulty in bowel movements)? Yes No 11. History of Glaucoma? Yes No 12. Have you been previously treated by a physician for weight management? Yes No Please explain (e.g. prescribed diets, medications or surgical interventions). 13. Have you taken, or are you currently taking any stimulant drugs or appetite suppressants, including over the counter energy preparations? Please explain. 14. Is there any history of psychiatric illness, requiring treatment? Yes No Please explain and list any medications that have been prescribed for your condition (e.g. depression, anxiety, bipolar disorder). Past Medical History: (check all that apply) Kidney Disease Scarlet Fever Osteoporosis Lung Disease Jaundice Blood Transfusion Rheumatic Fever Bleeding Disorder Thyroid Disease Ulcers Gout Heart Disease Anemia Heart Valve Disorder Psychiatric Illness Tuberculosis Gallbladder Disorder Alcohol Abuse Drug Abuse Eating Disorder Other: Pneumonia Arthritis Cancer Liver Disease Nutrition Evaluation: 1. Present Weight: Height (no shoes) : Desired Weight: 2. What time frame would you like to be at your desired weight? 3. What weight at 20 years of age: Weight one year ago: 4. What is the main reason for your decision to lose weight? 5. When did you begin gaining excess weight? (Give reasons, if known): 6. What has been your maximum lifetime weight (non-pregnant) and when?

4 7. Previous diets you have followed: Please give dates and results of your weight loss: 8. Is your spouse, fiancée or partner overweight? Yes No 9. By how much is he or she overweight? 10. How often do you eat out? 11. What restaurants do you frequent? 12. How often do you eat fast foods? 13. Who plans meals? shops cooks 14. Do you use a shopping list? Yes No 15. What time of day and what time do you shop for groceries? 16. Food allergies: 17. Food dislikes: 18. Foods you crave: 19. Any specific time of the day or month when you crave food? 20. Do you drink caffeinated beverages? Yes No If yes please give examples of daily amounts: 21. Do you eat chocolate to excess? Yes No How much daily? 22. Do you drink alcohol? Yes No What? How much? Frequency? 23. Do you use a sugar substitute? Yes No If yes what type and how much? Do you use butter? Yes No Do you use margarine? Yes No 24. Do you awaken hungry during the night? Yes No 25. What are your worse food habits? 26. Snack habits: What and how much? When do you eat these snacks? 27. When you are under a stressful situation at work or family related, do you tend to eat more? 28. Do you think you are currently under going a stressful situation or an emotional upset? Explain:

5 29. Typical Breakfast Typical Lunch Typical Dinner Time eaten: Time eaten: Time eaten: Where: Where: Where: With whom: With whom: With whom: 30. Describe your usual energy level: 31. Activity Level: (Please mark only one) Inactive - no regular physical activity, e. g.: a sit- down job. Light activity-no organized physical activity during leisure time. Moderate activity-occasionally involved in activities such as weekend golf, tennis, jogging swimming or cycling. Heavy activity-consistent lifting, stair climbing, heavy construction, etc., or regular participation in jogging, swimming, cycling, or active sports at least three times per week. Vigorous activity-participation in extensive physical exercise for at lease 60 minutes per session, 4 times per week. 32. Behavior style: (mark only one) You are always calm and easygoing. You are usually calm and easygoing. You are sometimes calm with frequent impatience. You are seldom calm and persistently driving for advancement. You are never calm and have overwhelming ambition. You are hard driven and can never relax. 33. Please describe your general health goals and improvements you wish to make: Plan: [ ] Diet Discussed [ ] Exercise Prescription Discussed [ ] Counselor/Therapist Refer To: [ ] Behavior Lifestyle Discussed [ ] Medications [ ] Side Effects [ ] Informed Consent Signed [ ] Waiver of Childproof Signed [ ] Bill of Rights signed and witnessed This information will assist us in assessing your particular problem areas and establish your medical management. Thank you for your patience in completing this form. Reviewed: Peter Ruggiero M.D. Date:

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