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Thank you for choosing Guthrie Weight Loss Center. If you wish to make an appointment with our office, this packet is to be filled out in its entirety. You may return the packet to the Guthrie Weight Loss Center by mail or in person; we will then contact you to schedule an appointment. Patient Information Address / City / State / ZIP Name Date of Birth Gender (circle one) Male - Female Home Phone Cell Phone Work Phone E-mail address Employer Emergency Contact (Name and relation) Marital Status Single - Married - Divorced - Widow - Other Spouse s Employer (if applicable) Emergency Contact Phone Referral Source (circle one) Family/friend - Physician - Website - Web ad - Radio/TV ad - Print ad - Insurance company - Other: Physician Information Referring Physician / PCP (Name) Location (city, state) Date of last visit Date of next visit Preferred Pharmacy Phone Policyholder Name Insurance Information (if other than patient) Primary Insurance (i.e. BC/BS, Aetna, etc.) Primary Insurance Phone # ID / Policy Number Group Number Secondary Insurance Policyholder Name (if other than patient) Secondary Insurance (if applicable) Secondary Insurance Phone # ID / Policy Number Group Number The information provided is correct to the best of my knowledge. My signature below authorizes Guthrie Weight Loss Center to communicate with me via email, phone, or other means indicated. Signature*: Date:

Medical History You may not be familiar with some terms, but mark all that apply. CONDITION MANAGEMENT (Check all that apply) CONDITION MANAGEMENT (Check all that apply) Type 2 Diabetes Diet controlled Oral Medication Insulin Congestive Heart Failure (CHF) Hospitalization Hypertension (High Blood Pressure) High cholesterol (Hyperlipidemia) Diet controlled Usual reading: / Diet controlled Coronary Disease (Heart Attack, Angina) Liver Disease (List type: ) Stents: Bypass surgery Obstructive Sleep Apnea Using CPAP CPAP prescribed, not used Using mouth spacer Kidney Disease Dialysis Creatinine: Gastroesophageal Reflux (GERD, heartburn) Diet controlled Venous Insufficiency Swelling Compression hose Ulcers Arthritis / Joint Pain Physical therapy Prior surgery COPD (Emphysema or Chronic Bronchitis) Oxygen Back Pain Chiropractor / PT Other: Asthma Frequency of inhaler use: Depression Therapy / counseling Gallstones Infertility / Polycystic Ovaries Blood Clots in Leg / Lung (DVT/PE) Blood thinner current Blood thinner past IVC filter Irregular Menstrual Cycles Cancer (Type: ) Stress Urinary Incontinence (leakage) Using pads Leakage frequency: Other: Thyroid disease Prior thyroid surgery Other:

Obesity History 1. How long have you been obese? 2. Highest adult weight (lbs.)? 3. Lowest adult weight (lbs.)? 4. What is your current weight? 5. What is your desired weight? And In what time frame do you want to get to your desired weight? 6. When did you begin gaining excess weight? 7. What do you think is the reason for your weight gain? 8. What do you see as your two biggest barriers to weight loss? 9. How does your weight limit you? Family History You may not be familiar with some terms, but mark all that apply. CONDITION FAMILY MEMBER CONDITION FAMILY MEMBER Type 2 Diabetes Hypertension (High Blood Pressure) High cholesterol (Hyperlipidemia) Obstructive Sleep Apnea Gastroesophageal Reflux (GERD, heartburn) Arthritis / Joint Pain Congestive Heart Failure (CHF) Coronary Disease (Heart Attack, Angina) Liver Disease (List type: ) Kidney Disease Venous Insufficiency COPD (Emphysema or Chronic Bronchitis)

Back Pain Asthma Depression Gallstones Infertility / Polycystic Ovaries Irregular Menstrual Cycles Thyroid disease Blood Clots in Leg / Lung (DVT/PE) Cancer (Type: ) Sudden Death Psychiatric Disease Other: Stroke Other: Review of Body Systems You may not be familiar with some terms, but mark all symptoms that you are currently experiencing. GENERAL EYES EARS / NOSE / THROAT Fevers or chills Loss of appetite Excessive sweating Burning / irritation Change in vision Double vision Earaches Nasal congestion Ringing in ears Cough Nosebleeds Sore throat URINARY SKIN / BREAST HEMATOLOGIC Pain with urination Kidney stones Trouble starting/stopping stream Leakage (incontinence) Skin lesion (new) Rash Changing mole Breast lump (new) Easy bruising Prolonged bleeding Swollen glands RESPIRATORY CARDIOVASCULAR GASTROINTESTINAL Wheezing Pneumonia Shortness of breath Asthma Chest pain Chest pressure Palpitations / irregular heartbeats Nausea / vomiting Constipation Diarrhea Abdominal pain MUSCULOSKELETAL NEUROLOGICAL SLEEP Back or neck pain Painful joints: Muscle aches Muscle weakness Numbness or tingling Seizures Headaches Dizziness / vertigo Snoring loudly (according to partner) Fatigue during daytime / nodding off

Mental Health History 1. Are you now or have you been in the past diagnosed with depression or bipolar disorder? 2. Are you now or have you been diagnosed in the past with anxiety? 3. Are you now or have you been in the past diagnosed with any other mental health issues? 4. Have you ever been diagnosed or treated for an eating disorder? If YES, what and how were you treated? 5. Were you ever the victim of sexual abuse? Surgical History You may not be familiar with some terms, but mark all that apply. Add anything not listed. SURGERY TYPE APPROACH YEAR Appendix (appendectomy) Gallbladder (cholecystectomy) Hysterectomy Previous bariatric surgery List type: Laparoscopic Open I don t know Laparoscopic Open I don t know Laparoscopic Open Vaginal Laparoscopic Open I don t know Hospital: Social History TOBACCO USE ALCOHOL USE SUBSTANCE USE FITNESS HISTORY Fill out everything to the best of your knowledge. Do you smoke? YES - NO Do you drink? YES - NO Did you ever used to smoke? YES - NO I quit in (yr) Packs/day: Years: drinks per week of (circle) beer / wine / liquor Willing to quit? YES - NO Do you use any of the following: Marijuana Ecstasy Heroin Meth(amphetamines) Cocaine Other: Has a physician ever told you NOT to participate in a fitness or exercise program? YES - NO Is there anything that will prevent you from participating in a fitness program? YES - NO REASON: REASON:

Allergies List all medication/food allergies, or indicate: I have no known allergies. MEDICATION NAME REACTION Medications List all current medications. MEDICATION DOSE SCHEDULE PURPOSE Example: Metformin 500mg 1 pill twice a day diabetes

Weight Management History LENGTH OF TIME (MONTHS) YEAR WEIGHT LOST (lbs) WEIGHT RE-GAINED (lbs) Example: Low calorie diet 10 months 2002 30 lbs. 15 lbs. Low calorie diet Low fat diet Atkins diet Optifast / Medifast Phen-Fen Other prescription meds (Name: ) Diet shots (B12, etc.) (Name: ) Non-prescription diet pills (Name: ) Doctor-supervised diet Registered Dietician (RD) Exercise program Nutrisystem T.O.P.S. Weight Watchers Jenny Craig Other: Other: The entire weight management history must be filled out, to the best of your knowledge. Do not write All my life or Years but be specific, as close as you can recall.

Sleep Assessment 1. How many hours of sleep do you get per night? 2. Do you feel rested when you wake up in the morning? 3. Has anyone ever told you that you stop breathing while you sleep? 4. How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired. Use the scale below to choose the most appropriate number for each situation: 0= no chance of dozing 1= slight chance of dozing 2= moderate chance of dozing 3= high chance of dozing SITUATION CHANCE OF DOZING SITUATION CHANCE OF DOZING Sitting and reading Watching TV Sitting inactive in a public place (theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic

Nutrition Evaluation 1. How often do you eat out? 2. How often do you eat fat foods? 3. Who plans meals at your home? 4. Who does the cooking at your house? 5. Who does the shopping for food? 6. Do you use a shopping list? 7. Do you have any food allergies? 8. Are there any foods you dislike? 9. Are there any foods you crave? 10. When do you tend to have cravings? 11. Do you awaken hungry at night? If YES, what do you do? 12. What do you think are your worse food habits? 13. How does stress affect your eating habits? 14. Are you currently undergoing a stressful situation?

Nutrition Evaluation Continued 1. How much water do you drink in a day? 2. How much coffee do you drink? How do you take your coffee (cream, sugar, sweetener)? 3. How much tea do you drink? Sweet tea? YES or NO 4. How much juice do you drink? 5. How much soda do you drink? 6. Are there other nonalcoholic beverages that you like? 7. Do you drink alcohol? If YES, what do you drink, how much, and how often? 8. What is your last 24 hour recall of snacks and/or meals? Meal Time Eaten Where With Whom Breakfast Lunch Dinner Snacks Snacks

Exercise History 6. Do you have any limitations or injuries that make exercise difficult? If YES, please describe. 7. Do you engage in any consistent exercise now? If YES, please describe. If NO, please tell us why. 8. Have you enjoyed exercise in the past? If YES, please describe. If NO, tell us what you did not like. 9. Have you ever stuck to a consistent exercise plan? If YES, for how long? 10. If you have never been able to stick to a consistent exercise plan, what has prevented you from doing so? Have you attended a Guthrie Weight Loss Center Surgical seminar? Demographics Date: Location: RACE: Asian Black or African-American Caucasian or White Native American Hawaiian or Pacific Islander I choose not to identify ETHNICITY: Latino or Hispanic Not Latino or Hispanic LANGUAGES SPOKEN: First: Other: YES - NO Upon completion, submit this information packet either in person or by mail to: Guthrie Weight Loss Center Guthrie Clinic One Guthrie Square Sayre, PA 18840 We want to safeguard your personal information as best we can. Please do not email or fax this packet. Thank you, and best of luck as you begin this journey!

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