INITIAL WEIGHT LOSS CONSULTATION

Similar documents
Name (Last Name, First Name): SSN #: Date of Birth: Age: Sex: M F Other. Address: Home phone: Work phone: Cell phone:

New Patient History Patient Name: Age: Date of Birth:

Surgical History Please list all operations and dates:

Patient Medical History Form

SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:

INITIAL EVALUATION FORM

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

PATIENT HISTORY FORM

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

Initial Consultation

Gender: M F Race: Caucasian African American Hispanic Other

Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

GUPTA SPORTS & SPINE CENTER

12 Reasons. Why I Want to Reach My Goal Weight

PATIENT HISTORY FORM

Salt Lake Orthopaedic Clinic Initial Visit Form

Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?

Adult Health History for New Patient

Patient Information. Insurance Information

Welcome to About Women by Women

Legacy Weight and Diabetes Institute New Patient Information

New Patient Health Information

Initial Medical Questionnaire Please complete this questionnaire and bring it with you to your first appointment.

Welcome to our Center! We are so glad you have chosen our center to assist you with your weight loss goals!

PeaceHealth Southwest Weight Loss Surgery Process

Patient Name Date of Birth Age. Other phone ( ) . Other

Patient Interview Form

New Patient Questionnaire

Date of Birth: City: State: Zip: Home phone: Who is your primary care physician?

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

Providence Medical Group

Comprehensive Patient History Form

Patient Interview Form

PATIENT HEALTH HISTORY

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency

Name(last, first): Home Phone: Cell Phone: address: Date of birth: SSN:

New Patient Information

Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:

Medical History Form

JOHN MICHAEL ROACH, MD

Phone (573) * Fax (573) PATIENT HISTORY FORM. Name Date of Birth M/F. Reason for Appointment Height

Patient History Form

MEDICAL/SURGICAL HISTORY FORM

Mercy Metabolic and Bariatric Surgery Program Questionnaire

Weight Loss- Medical History Form

MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY

Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire

FAMILY MEDICINE New Patient Medical History Form

DIVISION OF CARDIOLOGY

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

Patient Health History

GUPTA SPORTS & SPINE CENTER

Patient Interview Form

Creve Coeur Family Medicine, LLC

History of Present Illness Please answer the following questions

Patient Interview Form

PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

Patient Interview Form

EGEA MEDICAL WEIGHT LOSS CENTER. Name: Age: Sex: M F. 6. History of Diabetes? Yes No At what age:

AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

Name: Age: Sex: M F. 1. Are you in good health at the present time to the best of your knowledge? Yes No

Byers Wellness Center- Patient Information for HCG Program. General Patient Information

Health Questionnaire

SELF-REPORTING HEALTH HISTORY

Bariatric Intake Form

New Patient Questionnaire. Name DOB Date

UnityPoint Clinic - Cardiology

*** ADDRESS: (If address is not provided, you MUST write Patient denied.)

New Patient Medical History Form

DATE OF BIRTH: MELANOMA INTAKE

Integrative Consult Patient Background Form

Patient Interview Form

Patient Information. Legal Name: First Middle Last. Street City State Zip

Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female

Amarillo Surgical Group Doctor: Date:

Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX Phone (903) Fax (903)

New Patient Medical Questionnaire DATE:

Health History Questionaire

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.

PATIENT REGISTRATION

Medication Allergies

PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT

Patient History Form

New Patient Questionnaire

BARIATRIC PROGRAM PATIENT HEALTH HISTORY QUESTIONNAIRE (PLEASE PRINT CLEARLY)

MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

Transcription:

INITIAL WEIGHT LOSS CONSULTATION Name: Date: Date of Birth: Age: Weight: Height: Weight loss goal: Name of Family Physician who will receive your progress reports: Office Address: Office Phone: Review of Symptoms Do you now or have you ever had any problems related to the following systems? Please check all that apply. General Skin Fatigue Fever Chills Night Sweats Rash Weight gain Weight loss Skin ulcers/cellulitis Skin fold irritations Skin fold infections Hair loss Dry Skin Pulmonary Choking at night Frequent waking Daytime drowsiness Wheezing Emphysema Snoring Short of breath Persistent cough Asthma COPD Gastrointestinal Heartburn/acid reflux Abdominal paid Constipation Diarrhea Blood in stool Irritable bowel Nausea Vomiting Change in appetite Genitourinary Urinary incontinence Blood in urine Burning on urination Prostate problems Gynecological Vaginal infections Irregular periods Last menstrual period Are you pregnant Current Contraception Cardiac Chest pain/angina Heart attack/cad Swelling of ankles Irregular heartbeat Palpitations Heart murmur Neurological Dizziness Migraines/headaches Numbness/tingling Hearing loss Vision Loss Musculo Skeletal Back/neck pain Difficulty walking Exercise limitations Joint pain Limited mobility--- use cane, crutch, or wheelchair Psychiatric Depression Sexual abuse Alcohol abuse Dipolar disorder Anxiety/panic issues ADD/OCD Drug Abuse Eating Disorder Medical History Please check all that apply Anemia Asthma Tuberculosis Incontinence H-pylori Bleeding disorder COPD HIV/AIDS Thyroid problems Gastritis Blood clots in legs/lungs Emphysema Hepatitis Heartburn/reflux Hiatal Hernia Stroke/TIA/Seizure Sleep apnea Kidney disease Diabetes Stomach ulcers Congestive heart failure High cholesterol Rheumatic fever Kidney stones High blood pressure Previous heart attack High triglycerides Gout Cancer Arthritis Irregular heart beat Stent placed Diverticulitis Stress test Echo Coronary artery disease Polycystic Ovarian Syndrome (PCOS) Liver disease Liver disease requiring protein restriction Kidney disease requiring protein restriction

Past Surgical History (Please check all that apply and write year of surgery next to procedure) Gallbladder Hernia Hemorrhoids Heart Surgery C-Sections Breast Colonoscopy Angioplasty/Stents Hysterectomy Appendix Colon surgery Previous weight loss surgery Tubal Ligation Thyroidectomy Knee surgery Pacemaker Back surgery Joint Replacement Surgery Other surgery Complications with any surgery: MEDICATIONS: Please list all daily medications including over the counter medications and vitamins, herbs or supplements Name Dosage Frequency Year Started MEDICATION ALLERGIES: Please list any known allergies or sensitivities and the reaction you had. Name Reaction OTHER ALLERGIES AND SENSITIVITIES: Please list any known allergies or sensitivities and the reaction you had. NAME REACTION Latex (yes) (no) IVP Dye (yes) (no) Tape (yes) (no) Iodine (yes) (no) FAMILY HISTORY PLEASE CHECK ALL THAT APPLY Mother Father Brother Sister Grandmother Grandfather Diabetes High Blood Pressure Heart Attack Stroke Sleep Apnea Cancer

SOCIAL HISTORY PLEASE CHECK ALL THAT APPLY Marital Status: ( ) Single ( ) Married ( ) Divorced ( ) Separated ( ) Widowed Religious preference :( ) Catholic ( ) Baptist ( ) Methodist ( ) Lutheran ( ) Jehovah Witness ( ) Atheists ( ) Other Education: ( ) Grade School ( ) High School ( ) College ( ) Graduate School ( ) GED What type of work do you do? Number of people living in your home: Smoking History: ( ) Never smoked ( ) Smoke now ( ) Used to smoke, stopped packs/day for yrs Chemical dependency: ( ) None ( ) Using now ( ) Used to use Substance used Alcohol history: ( ) Beer ( ) Wine ( ) Liquor How often? ( ) Daily ( ) Weekly ( ) Occasionally ( ) Rarely Exercise history: ( ) Rarely ( ) occasionally ( ) 1-2 times a week ( ) 3-4 times a week ( ) 5 times or + a week Has a doctor or healthcare professional ever told you not to exercise? Do you know of a reason why you should not exercise? Food Allergies/ Sensitivities Cocoa Milk Protein Corn Soy Eggs Gluten Aspartame MSG Lactose Other: Vegetarian Weight- Loss Eating Habits (Please check all that apply) Eating high-fat foods Eating too many sweets Eating too quickly Uncontrollable binges Overeating when alone Using food as reward Only eat once a day Eat out too much No meal planning No meal packing Purge after meals Use laxative or diuretics Waken hungry at night Overeating at social events Drink too much soda/ tea/ sweetened beverage Eating in reaction to boredom Foods you crave: Foods you dislike: How often do you eat out: where most often: Who plans meals: Who Cooks: Who Shops: Typical Breakfast Typical Lunch Typical Dinner Snacks Time eaten: Time eaten: Time eaten: Time eaten: Where: Where: Where: Where: With whom: With whom: With whom: Maximum Weight (non-pregnant) Year: Goal Weight Last time at this weight: In what time frame do expect to be at your goal weight:

Psychosocial History: Are you at present undergoing any major lifestyle change (marriage, divorce, job change, death of someone important to you?) If so describe: What other commitments do you have that might interfere with you participating in with your weight loss and wellness program? When you are under stressful situations at work or family related, do you tend to eat more? Explain: What benefits do you hope to gain from being in this program other than losing weight? Who do you feel will be supportive of your weight loss and changes in lifestyle? (Check and name your choices) ( ) Spouse ( ) Children ( ) Roommate(s) ( ) Parent ( ) Friend(s) ( ) Co- worker(s) ( ) other Who do you feel may NOT be supportive of your weight loss and changes in lifestyle? (Check and name your choices) ( ) Spouse ( ) Children ( ) Roommate(s) ( ) Parent ( ) Friend(s) ( ) Co- worker(s) ( ) other List weight loss methods you have tried, please be as specific as possible (eg. Nutrisystem, Jenny Craig, Starvation, Medications, Spa, Hypnosis, Weight Watchers, Adkins, South Beach, HCG...) Weight Loss Method Ex: Grapefruit Diet Amount of time weight loss maintained Ex: 2 months Reason why you stopped treatment Ex: interaction with meds Problems during treatment Ex: dizziness If you have already had surgery and are here for aftercare, please fill out this section Surgery date: ( ) Band ( ) Bypass ( ) Sleeve ( ) Plication Surgeon: Weight at time of surgery: Lowest weight achieved How many fills have you had? Current diet: ( ) Clear Liquids ( ) Pureed ( ) Soft ( ) Regular Notes: Physician/NP: Date:

12 Reasons Why I Want to Reach My Goal Weight Name: Date: Before writing your reasons down, give them some thought. It is important that these 12 reasons be true personal goals and desires. They should not be generalizations or what you think would please others because they will be used as your personal motivator. 1 2 3 4 5 6 7 8 9 10 11 12 Take a few moments from time to time each day to thoughtfully read through this list. This is called mental programming. The original of your 12 reasons list is retained in your medical file. You will be given a copy to carry at all times. We suggest that you also transfer your list onto a 3 x 5 card which may be more convenient.

Make a promise to yourself now: I will read the entire card whenever I am confronted with a difficult food situation. Reading the list will clearly reinforce your personal commitment to take control of your health and self-esteem.

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback