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Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their specialty: Are you taking any medications at the present time? LIST ALL Name of Medication Reason 1. 2. 3. 4. 5. 6. Allergies: Do you have any food allergies? If so, please list: Do you have any medication allergies? If so, please list: Cardiovascular Health: Do you have history of arrhythmia (irregular heart beat) Have you had a heart attack or chest pain Do you have high blood pressure? Are you taking medication for blood pressure: Do your feet or ankles swell? High cholesterol? Blood Sugar or Diabetes: Do you tend to be hypoglycemic? Do you have diabetes? (if no, skip to next section) Type I insulin dependent (insulin injections only); Type II non-insulin dependent (diabetic pills); Type II insulin dependent (diabetic pills and insulin). Is your blood sugar level monitored? If so, by whom? Myself Physician Other (specify): Are you taking any medication for diabetes? Kidney Health: Have you been diagnosed with kidney disease? Have you ever had Gout? Liver Health: Do you have liver problems? If so, please specify: Colon Health: Do you have: Irritable Bowel Colitis Diarrhea Diverticulosis Crohn s disease Constipation If so, are you under the care of a physician? Are you taking any medication? 1

Stomach/Digestive Health: Do you have: Acid Reflux Gastric Ulcer Heartburn Celiac Disease? If so, are you under the care of a physician? Are you taking any medication? Thyroid Function: Do you have thyroid problems? If so, are you under the care of a physician? Are you taking any medication? Emotional Evaluation: Do any of the following apply to you? Depression Anxiety Panic Attacks Bulimia (or history of) Anorexia (or history of) Inflammatory Conditions: Do any of the following apply to you? Migraines Fibromyalgia Rheumatoid Arthritis Lupus Osteoarthritis Chronic Fatigue Syndrome Psoriasis Other autoimmune or inflammatory condition: Headaches: History of frequent headaches Migraine? Medications for headaches? General: Do you now or have you ever had cancer? Are you in cancer remission? If so, please specify and indicate for how long: If so, are you under the care of a physician? Are you taking any medication? If so, please list: Are you generally fatigued or have low energy? Do you get cold easily? Do you have cold hands/feet? Do you have other health problems? If so, please specify: If so, are you under the care of a physician? Are you taking any medications not listed above? If so, please list: (Women only): Are you pregnant? Are you breastfeeding? Not applicable Pregnancies: # Dates: Date of last menstrual cycle if still having periods: Approximate date or year of last cycle if no longer having periods: Check off the situations that apply to you currently: Irregular Periods Amenorrhea Painful Periods Heavy periods Hysterectomy Menopause Hormone Replacement therapy (HRT) Uterine fibroma Fibrocystic Breasts Cancer (uterus, breast) If so, are you under the care of a physician? Are you taking any medication? If so, please list: 2

Vitamin and mineral Supplements: Please List what you currently take Current Vitamin, Herb or Supplement Name Reason 1. 2. 3. 4. 5. Age Diseases? Cause of death Overweight? FATHER YES NO MOTHER YES NO BROTHERS YES NO SISTERS YES NO YES NO Has any blood relative had the following? Glaucoma YES NO Who: Asthma YES NO Who: High Blood Pressure YES NO Who: Kidney disease YES NO Who: Diabetes YES NO Who: Tuberculosis YES NO Who: Psychiatric disorder YES NO Who: Heart Disease/ Stroke YES NO Who: PAST MEDICAL HISTORY (CHECK ALL THAT APPLY) POLIO MEASLES PLEURISY JAUNDICE MUMPS LUNG DISEASE SCARLET FEVER LIVER DISEASE RHEUMATIC FEVER WHOOPING COUGH CHICKEN POX ULCERS BLEEDING DISORDER NERVOUS BREAKDOWN ANEMIA GOUT THYROID DISEASE TUBERCULOSIS HEART VALVE DISORDER HEART DISEASE DRUG ABUSE GALLBLADDER DISORDER PHYCHIATRIC ILLNESS PNEUMONIA EATING DISORDER ALCOHOL ABUSE CHOLERA MALARIA TYPHOID FEVER ARTHRITIS CANCER BLOOD TRANSFUSION TONSILLITIS OSTEOPOROSIS OTHER (DESCRIBE) I hereby certify the information I have provided is accurate. I understand that inaccurate information may adversely affect the outcome of my weight loss program. Signature Date 3

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