NEW PATIENT QUESTIONNAIRE

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Consultant Name: NEW PATIENT QUESTIONNAIRE Health Care Analysis CONGRATULATIONS! You ve taken an important step in your commitment to managing your weight. We look forward to working with you. Our Program offers an individualized approach to weight management. We need to know you better so we can plan a program to meet your specific needs. You can assist us by completing this questionnaire. In addition to helping us plan your individualized program, this questionnaire will help to measure your progress over time. Directions: Some of the information requested in this questionnaire is very personal and may be difficult to remember. Try to be as accurate and honest as you can. Unless indicated otherwise, please select only one answer for each question. Answer every question that is appropriate for you. Participant Information: First Name: MI: Last Name: Height: Ft. In. Weight: lbs. Date: / / Copyright 2017

Today s Date: First Name: Last Name: Email: Address: City: State: Zip Code: Primary Phone: Date of Birth: Age: Gender: Male Female Height: Weight: How did you hear about us?: If referred by someone, who?: Please answer the following questions honestly so we can do our best to help you reach your goals Who encouraged you to lose weight?: How important to you is it to lose weight?: What important reason, special occasion, or goal date do you have to lose weight?: How many pounds would you like to lose?: How fast do you want lose the weight?: Would you commit to one visit a week?: If no, please explain: Have you ever attended any other weight reduction centers, if so, which ones?: What kinds of diets have you tried on your own?: What is the longest you have been able to stick with a diet?: Does your family support your weight loss efforts?: Have you been advised by your family physician to lose weight?: If you answered Yes, what is your doctor s name?: Do you eat because of emotions?: If you answered yes, please explain: Copyright 2017

What is most important to you in deciding to use our services? (Please check all that apply): Effectiveness My results are my top priority. Time I want results quickly. Service I need extra support along the way. Ease I have a difficult time losing weight. On average, which of the following reflects your daily eating habits? (Please check all that apply): 3 meals with healthy snacks 3 meals 2 meals or less Skip breakfast or other meals Generally eat on the run No regular eating pattern Often crave sweets/carbs Graze; small, frequent meals (How many per day? ) Are you vegetarian/vegan? Current level of exercise (Please check one that applies): None Light exercise (1-3 times per week, easy pace, stretching, walking, etc.) Moderate exercise (2-3 times per week, moderate pace, some weights, etc.) Heavy exercise: (3-4 times per week, vigorous pace, weights, fast running, etc.) Health Information Please list all medications you are currently taking, including doses and reasons for taking Medication: Dose: How often: Reason: Prescribing M.D. Have you ever been hospitalized, under medical care, or checked into rehab for alcohol or drug treatment?: If you answered yes, please explain: Copyright 2017

Initial Confidential Patient Case History Please check the appropriate box for any of the following symptoms which you now have or have had previously. We want all the facts about your health before we accept your case. THIS IS A CONFIDENTIAL HEALTH REPORT. O OCCASIONAL F FREQUENT C CONSTANT O F C GENERAL: Allergy Chills Convulsions Dizziness Fainting Fatigue Fever Headache Loss of sleep Loss of weight Weight gain Nervousness/depression Neuralgia Numbness Sweats Tremors MUSCLE & JOINT: Arthritis Bursitis Foot trouble Hernia Low back pain Lumbago Neck pain or stiffness Pain between shoulders Pain or numbness in: Shoulders Arms Elbows Hands Hips Legs Knees Feet Painful tail bone Poor posture Sciatica Spinal Curvature Swollen joints O F C GASTRO-INTESTINAL: Belching or gas Colitis Colon trouble Constipation Diarrhea Difficult digestion Distension of abdomen Excessive hunger Gall bladder trouble Hemorrhoids Intestinal worms Jaundice Liver trouble Nausea Pain over stomach Poor appetite Vomiting Vomiting of blood EYES, EARS, NOSE &THROAT: Asthma Colds Crossed eyes Deafness Dental Decay Earache Ear discharge Ear noises Enlarged glands Enlarged thyroid Eye pain Failing vision Far sightedness Gum trouble Hay fever Hoarseness Nasal obstruction Near sightedness Nosebleeds Sinus infection Sore throat Tonsillitis WEIGHT: Inability to lose weight Food cravings Binge eating Water retention O F C CARDIO-VASCULAR: Hardening of arteries High blood pressure Low blood pressure Pain over heart Poor circulation Rapid heart beat Slow heart beat Swelling of ankles RESPIRATORY: Chest pain Chronic cough Difficult breathing Spitting up blood Spitting up phlegm Wheezing SKIN: Boils Bruise easily Dryness Hives or allergy Itching Skin eruptions (rash) Varicose veins HORMONE: Irregular Cycle Menopausal Symptoms Hair Loss Decreased Libido Memory Problems Hot flashes/ Night sweats GENITO-URINARY: Bed-wetting Blood in urine Frequent urination Inability to control kidneys Kidney infection or stones Painful urination Prostate trouble Pus in urine FOR WOMEN ONLY: Cramps or backache Excessive menstrual flow Hot flashes Irregular cycle Menopausal symptoms Painful menstruation Vaginal discharge Are you pregnant? Are you breastfeeding? 3

HABITS: Heavy Moderate Light None Alcohol Coffee Tobacco Drugs Exercise Sleep Appetite CHECK THE FOLLOWING CONDITIONS YOU HAVE HAD (present or past): Alcoholism Anemia Anorexia Appendicitis Arteriosclerosis Bulimia Cancer Candidacies Chorea Cold sores Depression Diabetes Diphtheria Drug Addiction Eczema Emphysema Epilepsy Fever Blisters Goiter Gout Heart disease High Blood Pressure Hypoglycemia Influenza Lumbago Malaria Measles Miscarriage Multiple sclerosis Mumps Pleurisy Pneumonia Polio Psychiatric Disorder Rheumatic Fever Recreational Drugs Scarlet fever Stroke Thyroid Imbalance Tuberculosis Typhoid fever Ulcers Venereal disease Whooping cough If you answered YES to any of the above conditions, please explain: ALLERGIES/INTOLERANCES None X-Ray Dye Sulfa Pollen Food Soaps/Lotions Environment Adhesives Medication Other: (List Substance and reaction) What is your major complaint? List surgical operation and years: 4

I understand that my patient file will be kept completely confidential unless I give written permission for my information to be released. Signature: Date: Printed Name: Consultant Notes: 5

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