1 General Information *Please complete in blue or black ink only* Name: Date: Address: City: State: Zip Code: Date of Birth: Email: Telephone: (Cell) (Home) (Work) Referred by: Occupation: Primary Doctor: Phone#: Address: Fax#: Preferred Pharmacy: Phone#: Address: Fax#: Medical History Please place an X next to any of the following conditions that you currently experience: High Blood Pressure Fainting Gallbladder Disease Urinary Tract Infections Heart Disease Chest Pain Shortness of Breath Irregular Heart Beat Swelling of Ankles/Feet Dizziness Varicose Veins Circulation Deficiency Stroke Severe Headaches Seizures/ Convulsions Numbness/ Tingling Indigestion Alcoholism Substance Abuse Nausea (frequent) Vomiting Abdominal Pain Diarrhea Constipation Diverticulitis/Diverticulosis Crohn s Disease Stomach/ Duodenal Ulcer Liver Disease (Hepatitis) Are you currently being treated for a condition not listed? YES NO Jaundice Diabetes Hypoglycemia Thyroid Disease High Cholesterol Level Glaucoma Anemia Blood Clotting Problem Gout Arthritis Osteoporosis Pain/ Swelling in Joints Kidney Disease Kidney Stones Chronic Cough Asthma Anxiety Depression Sleep Eating Sleep Apnea Malabsorption Migraines Hair Loss If so, please specify: Have you had any of the previous conditions in the past? YES NO Year If so, please specify? Surgical History Please list all operations and dates: Operation
2 Medications Please list all medications you are currently taking, including over-the-counter medications: Medication Dosage Frequency Please list any vitamin, mineral, nutritional supplements, herbs, or natural remedies you are presently taking: Are you allergic to any medications? YES NO If so, please specify: Gynecologic Information (for Women Only) Age at onset of menstrual cycle: Date of last period: Date of last pregnancy: Are you taking birth control pills? YES NO Do you experience fluid retention? YES NO If so, (please circle which description best fits) SLIGHT MODERATE SEVERE If you are not menstruating, age of menopause: Are you taking hormone replacement therapy? YES NO If you are experiencing menopause, are you having any symptoms? YES NO Specify: Family History Please list all medical history related to your relatives. Please include a history of diabetes, high blood pressure, cancer and heart disease, as well as any obesity and any other major health problems. Father Mother Use this column if living Use this column if deceased Age Sate of Health Cause of Death Age Brother(s) Sister(s) Spouse Signature: (Patient or Parent, if patient is under 18) Signature: (Physician)
Nutrition History Do you skip meals regularly? YES NO If so, which one(s)? BREAKFAST LUNCH DINNER Who in your household: Plans Meals? Cooks Meals? Shops for food? How many times per week do you eat at a restaurant? (please circle) 0-2 3-5 6+ How many times per week do you eat fast food? (please circle) 0-2 3-5 6+ How often are the following meals eaten out? Breakfast: Lunch: Dinner: How often do you snack between meals? Do you drink alcohol? YES NO If so, what type and how often? Do you smoke? YES NO If so, what and how often? Do you drink coffee? YES NO If so, how do you drink it and how often? Do you drink: (please circle) SODA UNSWEET TEA SWEET TEA HERBAL TEA ENERGY DRINKS If so, specify how often: What are the foods you crave the most? What are your worst food habits? Are you following any special diets (ex. Gluten free, low residue)? YES NO If so, specify: Please list any food dislikes: Please list and food allergies: List the foods your typical meals and snacks would consist of, including serving sizes: BREAKFAST LUNCH SNACK DINNER Exercise History Are your physical activities restricted for any medical reasons? YES NO If so, specify: Is exercising consistently a struggle for you? YES NO If so, specify: In general, how many times per week do you exercise? (please circle) NONE 1-2 3-5 6+ List the type of activities you most often do for exercise: TYPE DURATION & FREQUENCY INTENSITY (please circle) (easy) 1 2 3 4 5 6 7 8 9 10 (hard) (easy) 1 2 3 4 5 6 7 8 9 10 (hard) (easy) 1 2 3 4 5 6 7 8 9 10 (hard) 3
Behavioral and Emotional Issues Have you ever been diagnosed with an eating disorder? YES NO If so, when? Where and how were you treated for this? Do you frequently eat when you are not physically hungry? YES NO What feelings or situations trigger you to eat, even though you are not hungry: (circle all that apply) Anger Loneliness Anxiety/Nervousness Depression Stress Boredom Family Gatherings Social Situations Do you struggle with binge eating? YES NO If so, how frequently:(please circle) RARELY OCCASIONALLY FREQUENTLY Do you give too much time and thought to food? YES NO Is your weight affecting the way you live your life? YES NO Do you have feelings of guilt and remorse after overeating? YES NO Have you ever been diagnosed for a psychiatric disorder? YES NO If so, specify: What was the treatment? Personal Weight History Are there any personal problems or situations you have experienced or anticipate experiencing (ex. Relationships, job changes, family issues) that may affect your weight loss efforts? YES NO If so, specify: Were you overweight as a child? YES NO Were you overweight as a teenager? YES NO What was your lowest adult weight? lbs. at age. When did you begin gaining excess weight (give reasons, if known)? Are any of the following family members overweight? (circle all that apply) MOTHER FATHER BROTHER(S) SISTER(S) SPOUSE CHILDREN Which of the following weight loss programs have you tried in the past? (circle all that apply) DIET CENTER WEIGHT WATCHERS NUTRI-SYSTEM JENNY CRAIG OWN PROGRAM R.D.COUNSELING DETOX DIET ATKINS DIET LIQUID DIET OVEREATERS ANONYMOUS PHYSCIAN PROGRAM OTHER: How many times have you lost and regained weight? (please circle) 0-1 2-4 5-10 Other: If you have lost and regained weight, what are the main reasons you regained weight? How motivated are you to lose weight? A LITTLE SOMEWHAT MODERATELY EXTREMELY How committed are you to making lifestyle changes? A LITTLE SOMEWHAT MODERATELY EXTREMELY What is your goal weight (realistic, healthy weight)? 4 Signature: (Patient or Parent, if patient is under 18) Signature: (Physician)
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6 Informed Consent I,, have been informed of the possible side effects of using anorectic medications and of rapid weight loss. These side effects include, but are not limited to, the possibility of cardiovascular effects, depression, increased blood pressure, nervousness, dry mouth, trouble sleeping, diarrhea, drowsiness, or sedation, or impaired concentration, and the risk of gall bladder disease with rapid weight loss. I understand that a serious, but rare disease of pulmonary hypertension has been associated with the use of medications used for weight control and that the risk is estimated to be approximately 18 to 42 cases per million people (about 1 in 20,000) who take the medications, according to the International Primary Hypertension Study. I am not pregnant, and I understand that the use of these medications are contraindicated during pregnancy or breast feeding. I also understand that if I am planning elective surgery under general anesthesia, I am advised to discontinue the medications two weeks before the surgical procedure. I understand that complications with anorectic medications may continue to be found as their use increases in the general population. Nevertheless, after being fully informed of the nature, risk, possible alternative methods of treatment, and possible complications involved in the treatment of obesity by prescribed medications, including those used for conditions outside their PDR labeling, I herby consent and authorize such treatment and prescription by The Weigh Station physician. It has been explained to me that the medications, while decreasing appetite and increasing metabolism, work best with regular physical activity and moderate eating patterns. I also understand that in accordance with the American Society of Bariatric Physicians guidelines and the Virginia Board of Medicine regulations, a weight loss of at least a pound per week is necessary to continue medications past twelve weeks. I also understand that about 10% of patients may be minimally responsive to medications. It has been explained to me that obesity is a chronic disease and may require therapy over the long term. Also, I have been told that weight loss may slow or plateau periodically before I reach my goal size or weight and that doses may be adjusted or other medications substituted. It understand the maintenance policy as it has been explained to me. In accordance with Virginia law, The Weigh Station staff, employees or consulting physicians make no implied or stated otherwise guarantees of any programs or therapies. I also understand that I may be dismissed/ discharged from The Weigh Station, Inc. by its physicians or staff at will. I also understand that the use of tobacco products and alcohol is contraindicated with all of the programs available at The Weigh Station. Printed Name: DOB: Signature: Date: (Patient) Signature: Date: (Parent/Guardian, if patient is a minor under 18) Physician: Date:
7 Consent for Release of Medical Records I herby give consent to allow my medical records (i.e. x-rays, lab reports, progress notes, etc.) to be copied, received and added to my medical record upon request of the physicians at The Weigh Station. I herby give my consent for the physicians at The Weigh Station to discuss my medical history and my weight loss progress and weight loss program with consulting physicians and/or my primary care physician. Printed Name: DOB: Signature: Date: (Patient) Signature: Date: (Parent/Guardian, if patient is a minor under 18)