Centra Weight Loss Clinic Initial Appointment Questionnaire

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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: Name Date of Birth Physician Information Referring Physician / PCP (Name) Location (city, state) Date of last visit Date of next visit Have you had lab tests in the last 3 months? Yes No (If yes, please bring them to your initial visit or notify us so we may request these results.) Pharmacy Information Location (city, state) Preferred Pharmacy Phone number 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 CENTRA 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 Oral Medication Insulin Congestive Heart Failure (CHF) Hospitalization Hypertension (High Blood Pressure) High cholesterol (Hyperlipidemia) Usual reading: / 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) 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: Suicidality Currently Hospitalization Thyroid disease Prior thyroid surgery Other: Glaucoma -Angle Closed-Angle Other: Pregnancy/Breastfeeding Currently Desire pregnancy Currently breastfeeding Other:

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: I don t know I don t know Vaginal I don t know Hospital: Medications List all current medications. MEDICATION DOSE SCHEDULE PURPOSE Example only: Metformin 500mg 1 pill twice a day diabetes

Allergies List all medication/food allergies, or indicate: I have no known allergies. MEDICATION NAME REACTION Social History TOBACCO USE ALCOHOL USE SUBSTANCE USE 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 or have you use(d) any of the following: Marijuana Ecstasy Heroin Meth(amphetamines) Cocaine Other: Review of Body Systems Mark all symptoms that you are **currently** experiencing. GENERAL EYES Fevers or chills Loss of appetite Excessive sweating Burning / irritation Change in vision Double vision EARS / NOSE / THROAT Earaches Nasal congestion Ringing in ears Cough Nosebleeds Sore RESPIRATORY Wheezing Pneumonia Shortness of breath Asthma CARDIOVASCULAR Chest pain Chest pressure Palpitations / irregular heartbeats GASTROINTESTINAL Nausea / vomiting Constipation Acid reflux Diarrhea (heartburn/gerd) Abdominal pain URINARY SKIN / BREAST HEMATOLOGIC MUSCULOSKELETAL NEUROLOGICAL SLEEP Pain with urination Kidney stones Trouble starting/stopping stream Skin lesion (new) Rash Changing mole Breast lump (new) Easy bruising Prolonged bleeding Swollen glands Back or neck pain Painful joints: Muscle aches Numbness or tingling Seizures Headaches Dizziness / vertigo Snoring loudly (according to partner) Fatigue during daytime / nodding off

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. 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:

Obesity History 1. Highest adult weight (lbs)? 2. Lowest adult weight? 3. At what age did you FIRST consider yourself to be overweight? 4. What do you think is the reason for your weight gain? 5. What do you see as your 2 biggest barriers to losing weight? 6. How does your weight currently limit you? 7. What are at least 2 benefits of weight loss for you? 8. Family History of Overweight/Obesity? YES NO If yes, who? Sleep Assessment 1. How much sleep do you get at night, on average? 2. Do you feel rested when you wake up in the morning? 3. Has anyone told you that you stop breathing during your sleep? 4. How likely are you to fall asleep or doze in the following situations (NOT 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 1 hour without a break Lying down to rest in the afternoon (when able) Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic Exercise History 1. Do you have any limitations or injuries that make exercise difficult? Explain. 2. Do you engage in any regular exercise now? What kind? If not, why? 3. Have you enjoyed exercise in the past? Why or why not? 4. Have you ever stuck to a consistent exercise plan in the past? Why or why not?

Centra Weight Loss Clinic Upon completion, submit this information packet either in person or by mail to: Centra Weight Loss Clinic (Administration) 125 Nationwide Drive Lynchburg, VA 24501 We want to safeguard your personal information as best we can. Please do not email or fax this packet. We will contact you after receiving your packet. Clinic appointments will be held at: Centra Weight Loss Clinic 125 Nationwide Drive (2nd floor) Lynchburg, VA 24502 You may keep this sheet as a reference.

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