NEW PATIENT INTAKE FORM
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1 EW PATIET ITAKE FORM : Patient ame: MR: Please answer the following questionnaire as completely as possible.. Who is your primary care physician or family doctor?. How did you find out about the UAB Weight Loss Medicine clinic? Advertisement Select one: Billboard Flyer Health Fair ewspaper Friend/Family/Co-worker Internet Physician. What is the most you have weighed as an adult? Age at this weight? 4. What is the least you have weighed as an adult? Age at this weight? 5. What would you like to weigh? Age at your goal weight? 6. How has your weight changed during your life? (Check all that apply) Gradual increase with a small amount each year One or more rapid increase(s) in weight Up and down 7. What has caused you to gain weight in the past? (Mark all that apply) Death/Illness of Family/Friend, Describe: Illness, Describe: Injury, Describe: Quitting Smoking, Describe: Menopause, Describe: Medications, Describe: Stress, Describe:, Describe: 8. What are you hoping the UAB Weight Loss Medicine clinic can do for you? (Mark all that apply) Improve health/feel better Increase energy/allow me to do more daily activities Lose weight Prevent medical problems Reverse medical problems/allow me to stop medications, Describe: 9. Have you ever had weight loss surgery? If ES, Type of Surgery: : Weight lost:. Are you interested in weight loss surgery? Continue on ext Page
2 . Please indicate on list below which of following diet, diet aids, or programs you have tried in the past. For those you have tried, please enter the date started, date stopped, amount of weight loss, reason for stopping the diet, diet aid, or program, and reason for weight regain after stopping. ame of diet or program Check if Tried Start Stop Amount of Weight Lost Reason for Stopping Reason Weight Regained After Stopping Check if Tried Start Stop Amount of Weight Lost Reason for Stopping Reason Weight Regained After Stopping On your own Atkins or low carbohydrate UAB EatRight Jenny Craig utrisystem Weight Watchers Slimfast Optifast liquid diet (please specify) ame of Diet Supplement/Medication Adipex, Fastin (Phentermine) Alli, Xenical (Orlistat) Belviq (Locaserin) Dexatrim Herbal weight loss products Meredia (Sibutramine) Phen-fen Qsymia Redux (please specify). How many children under age 8 live with you? Select: Child(ren) Grandchild(ren) Continue on ext Page
3 . Please check if any family members are (or were) overweight or obese: (Mark all that apply) Spouse Son Daughter Mother Father Sister Brother Grandparent 4. Will your family support you in your weight loss? Maybe 5. Please indicate if you have a history of any of the following: Eating disorder t Sure Anorexia ervosa t Sure Binge eating t Sure Making yourself throw up/bulimia t Sure Eating so much at one time that you have to throw up t Sure Please answer the following Sleep/Restfulness questions: 6. On average over the past month, how many hours of sleep did you get per night? 7. Do you feel rested when you wake up? 8. Do you snore? 9. Have you ever been told to wear CPAP or BiPAP for sleep apnea?. How well have slept over the past month? Very Good I use it nights per week Fairly Good Fairly Bad Very Bad. Circle the choice for how likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven t done some of these things recently, try to work out how they would have affected you. Use the following scale for each situation: =Would never doze, =Slight chance of dozing, =Moderate chance of dozing, =High chance of dozing Chance of Dozing Would ever Doze Situation Slight Chance Moderate Chance High Chance Sitting and reading Watching TV Sitting in a public place (theatre or meeting) Passenger in a car for one hour or more Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after a lunch (without alcohol) In a car, while stopped for a few minutes in traffic TOTAL: Additional information related to exercise. On a typical day, which describes you? Mostly sitting Mostly walking Mostly heavy labor Unsure Continue on ext Page
4 . Please check or for the following: Do you enjoy exercise? Do you have a gym membership? Do you have exercise equipment at home? Do you exercise regularly? Do you have any negative feelings about exercise or had any bad experiences with exercise? Do you have any family members or friends who are willing to encourage you to exercise or possibly exercise with you? 4. How much exercise have you done in the PAST WEEK? Type of exercise: Length of exercise: minutes times per week 5. How long have you been exercising regularly (at least 5 minutes per week; such as 5 days a week for at least minutes per session)? months 6. What type of exercise are you currently involved in? (Mark all that apply) Aerobics classes Exercise videos Water/Pool Exercise Biking, Outdoor Hiking Pilates Weight training Biking, Stationary Running Crossfit/Boot Camp Stretching oga Zumba Swimming Elliptical Machine Walking ne 7. What type of exercise do you prefer or would enjoy the most? (Mark all that apply) Aerobics classes Exercise videos Water/Pool Exercise Biking, Outdoor Hiking Pilates Weight training Biking, Stationary Running Crossfit/Boot Camp Stretching oga Zumba Swimming Elliptical Machine Walking ne 8. Were you an athlete in school?, in high school, in college 9. How confident are you that you could increase the amount of exercise you do? (Check One) Very confident Moderately confident Only a little confident t at all confident. What are the major benefits of exercise for you? (Mark all that apply) Increased energy Improved health Improved arthritis Improved mobility. What are your major barriers to increasing the amount of exercise you do? (Mark all that apply) Lack of motivation Injuries Lack of time Health problems Lack of equipment Lack of access to exercise facilities :. How much time are you willing to commit to exercise? minutes/day 4 days/week Continue on ext Page
5 Additional information related to diet. How confident are you that you can follow a weight loss diet? (Check One) Very confident Moderately confident Only a little confident t at all confident 4. What are your major barriers to following a weight loss diet? (Mark all that apply) Access to healthy foods Access to cooking appliances (Stove, Microwave, Grill) Access to refrigerator and/or freezer Cost Healthy food doesn t taste good Hunger Lack of knowledge of food to eat/buy Family/household diet Food intolerances/dislikes Lack of family/peer support Religion Time to plan/prepare healthy diet Work atmosphere 5. How many times a day do you eat? 6. At what times of day do you eat? Morning Mid-morning on Afternoon Evening Late night/bedtime 7. How many people live in your home? Are meals eaten together? 8. Who does the grocery shopping? 9. Who cooks/prepares the meals? Self Self Spouse Spouse Parent Parent Middle of the night : : 4. Have you done or experienced any of the following in the past 6 months? Details/Comments Eating when stressed, emotional or bored Binge Eating Grazing or Frequent Snacking Eating in the middle of the night Skipping meals Eat out at restaurants or ordering take out Eating in front of the TV Eating at desk/computer/while working Eat more than one helping/large portion sizes Eating too fast Do OT feel satisfied or full after a meal 5 Continue on ext Page
6 4. Which of the following do you consume more than once a week? umber Per Day (Average) Regular soda Juice Sweet tea Alcoholic drinks Fried foods 4. Please indicate the number of servings of each of the below that you typically consume during an average day: Servings of fruit per day Servings of vegetables per day Servings of whole grains per day Servings of low fat dairy per day Servings of lean protein per day 4. Do you have any food intolerances or food allergies or are there particular foods you dislike? Please list: 44. Do you have any food cravings? Please list: PAST MEDICAL HISTOR Check if you have any of the following now or in the past: Diabetes, Age at diagnosis Polycystic Ovary Disease Depression Damage to Kidneys from Diabetes Kidney disease Anxiety Damage to Eyes from Diabetes Kidney stones Cataracts Damage to erves from Diabetes Dialysis Glaucoma Obstructive Sleep Apnea Pancreatitis Eye Disease High blood pressure Asthma Peripheral artery disease High cholesterol Pulmonary embolism Clotting Disorder Thyroid Disease Emphysema, COPD Rheumatoid Arthritis Arthritis Reflux/Heartburn Lupus Cancer, (Type) Crohn s disease Gout Heart Attack(s) Gallstones Rheumatologic Disease Heart murmur/valve problems Epilepsy (seizures) Liver disease Heart Failure Colitis Hepatitis Organ Transplant, (Type) Stroke HIV/AID medical conditions (please list): 6
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Last Name: First Name: MI: 1. Have you recently had any major family changes: If yes, please explain:
Adult Medical Questionnaire Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
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Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex:
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FIRST APPOINTMENT CHECKLIST Please bring the following items to your first appointment. Please bring the following documents to your first visit: Completed Patient Questionnaire (attached to this document).
If you arrive at the office without these forms, your visit may need to be rescheduled.
Dear, Your Appointment for the Welcome to Medicare Visit OR Annual Wellness Visit is scheduled on at There is NO CO-PAY for this visit, so it is free for you. The goal of this visit is to provide time
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BMI: % Body Fat Ideal Body Weight: What has triggered your weight gain? What has been an obstacle to your weight loss in the past?
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