New Patient Info (Please PRINT all information clearly) Date: / / Name: Date of Birth: / / SS# - - Sex: M / F Home Address: City State Zip Code: E-Mail Address: @.com Please indicate which phone number you would like for us to use as your primary number. Home phone: ( ) Work: ( ) Cell: ( ) Primary Care Physician: PCP Phone # Pharmacy name: Location: Pharmacy phone: Employer name: Employer Phone # Occupation: Do you have Medicare? Yes / NO Emergency Contact: Phone: Relationship: List all specialist/physicians you see other than your Primary Care Provider :(Ex: Dr. Hart cardiologist) 1) 4) 2) 5) 3) 6) How did you hear about our clinic? Radio (station) TV (Station) Bulletin Mailed to my house Family / Friend (name) Physician: (name) Magazine Newspaper Yellow Pages Internet: google, yahoo Other
PAST MEDICAL HISTORY Do you now or have you ever had: Past/current drug or alcohol problem Illegal / prescription drug misuse? Depression or anxiety Bipolarism or other psychiatric condition ADHD/ADD Insomnia/ other sleep disorders Obstructive sleep apnea (use a CPAP?) Prediabetes / Borderline Diabetes Diabetes Type 1(juvenile) Type 2 (adult Gestational Diabetes Insulin Resistance Dysmetabolic Syndrome Polycystic Ovarian Syndrome Thyroid Disorders (low / high / other Other chronic medical conditions (please list): Angina (chest pain) Arrhythmia (irregular heartbeat) Heart Burn Heart Disease Heart murmur Heart Attack / Heart Failure Heart Valve Problem Pacemaker or Defibrillator? Pacemaker or Defibrillator? History of fainting (syncope)? Stroke Pulmonary embolism / blood clots Other lung diseases? Type Anemia Asthma Glaucoma (Open or Narrow Angle?) High Blood Pressure High Cholesterol Epilepsy (seizures) Kidney disease Liver Diseases Bulimia Binge Eating Disorder Anorexia Past Surgical / Hospitalizations Surgery / Reason for Hospitalization Date Are you now or have you been experiencing any of the following? Weakness Constipation Brittle nails Dry, Coarse skin Gain in weight Swelling of face & eyelids Tired/fatigue Loss of hair Excessive / painful menses Slow speech Difficulty breathing Emotional Instability Slow movement Swollen feet Depression Coldness and cold skin Hoarseness Headaches Diminished sweating Loss of appetite Other Thick tongue Poor memory Other Coarse hair Nervousness Other Pale skin Heart palpitations NONE OF THE ABOVE
Family member with any of the following? If yes, who: Heart Disease/ Heart Attack/ Congestive Heart Failure Cancer: (list type) Hypothyroidism High Cholesterol High Blood Pressure Mental illness (depression, bipolar, etc.) Sudden death < 40 from medical condition Obesity/difficulty losing weight Stroke Diabetes or borderline diabetes Drug/alcohol/medication abuse: Other family medical conditions not listed above: CURRENT MEDICATIONS Drug allergies: No Yes To what? Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements: Name of drug Dose (include strength & number of pills per day) How long have you been taking this? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13 14 TOBACCO USE Do you smoke? Yes No If yes, how much / day? If yes, what age did you start? If you use to smoke when did you quit?
Patient Name: a Over the last 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things Not at all More than half the days Nearly every day Several days 0 1 2 3 b. Feeling down, depressed, or hopeless c. Trouble falling asleep, staying asleep, or sleeping too much. d. Feeling tired or having little energy. e. Poor appetite or overeating f. Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down g. Trouble concentrating on things such as reading the newspaper or watching television h. Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual i. Thinking that you would be better off dead or that you want to hurt yourself in some way Totals If you checked off any problem of the above chart, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Circle One Not Difficult Somewhat Difficult Very Difficult Extremely Difficult 0 1 2 3 Alcohol Screening Please answer the following questions Have you ever felt you should cut down on your alcohol drinking?...yes / No Have people annoyed you by criticizing your alcohol drinking?...yes / No Have you ever felt bad or guilty about your alcohol drinking?...yes / No Have you ever had an alcoholic beverage first thing in the morning to steady your nerves or get rid of a hangover?...yes / No
Exercise frequency? What is the intensity? How Long? None None None 1-2x/week Light (brisk walking, golfing, doubles tennis) Under 10 minutes 3-5x/week Moderate -biking, low impact aerobics 10-20 minutes Daily Moderately hard (running, aerobics, hockey) 20-30 minutes Very hard (Sprinting, speed swimming) over 30 minutes Comments: LIFESTYLE CHALLENGES Which of the following seem to sabotage your weight loss efforts: Lack of time for planning & self Eating late/waking up eating Eating too fast Comfort/stress eating Liquid calories such as alcohol Always hungry Enjoyment of food Specific food cravings like carbohydrates Boredom eating Social Events Mindless eating/habits Other Other Other Are you ready for lifestyle changes to be a part of your weight control program? Yes / No If yes, rate on a scale of 1-10(1 being a little ready, 10 being extremely ready) circle one 1 2 3 4 5 6 7 8 9 10 Are you willing to keep a food journal? Yes / No Please answer the following questions: Check yes or no Do you make yourself sick because you feel uncomfortably full?... Yes No Do you worry you have lost control over how much you eat?... Yes No Have you recently lost more than 15 pounds in a three-month period? Yes No Do you believe yourself to be fat when others say you are too thin?... Yes No Would you say that food dominates your life?... Yes No WHICH OF THE FOLLOWING DO YOU THINK WOULD HELP YOU ON YOUR WEIGHT LOSS JOURNEY? Check all that apply Learning how to eat real food and making my own healthy choices Food delivered right to my door to just eat that A program with mainly protein shakes/bars and one sensible dinner I suspect I might have an eating disorder and want further work-up What I really need is:
Past Weight Loss Medication History What weight loss medications have taken in the past? Did you have any problems with the medication? If yes, what? Date you last took the medication 1) Yes No 2) Yes No 3) Yes No 4) Yes No 5) Yes No 6) Yes No Past Weight Loss History What weight loss program/s have you tried in the past? Did you experience any problems with the weight loss program? Yes if yes, what Why do you think the program did not work? No Why do you think you struggle with your weight? FEMALE PATIENTS ONLY Are you pregnant? YES NO Are you breastfeeding? YES NO Date of your last period? Are your periods abnormal? YES NO Are you menopausal/ perimenopausal? YES NO What form of contraception do you use (including tubal ligation )
DIETARY INTAKE How many ounces of the following do you typically consume each day? (8oz=1cup) DRINKS Water Juice Milk Soda / Diet Soda Sports Drinks Unsweetened Tea Sweetened Tea Coffee Decaf Coffee Food Weaknesses (Check all that apply ) Portion Sizes Excess Carbohydrates Too little Protein Skipping Meals Other : What s a typical day of food like? BREAKFAST: LUNCH: DINNER: SNACKS: Do you have any food restrictions? YES NO If yes, please list Are you struggling with a current stressful situation or emotional upset? YES NO If yes, please describe: MISCELLANEOUS What is your lifetime non-pregnant maximum weight? What was your weight 1 year ago? lbs 5 years ago lbs 10 years ago lbs Overall Goals: What do you wish to accomplish by being here?