Patient Medical History Form Date Name Social Security Number - - DOB Age Height Weight BMI Primary care doctor For office use only Height Weight BMI Neck Goal Ideal BMI>45 Age>38 Apnea HbA1c Insulin Male Past Medical History Please circle the appropriate response Abnormal Bleeding Blood clots in the legs Rheumatic fever Blood clots to the lungs Thyroid problems Diabetes currently Tuberculosis Diabetes while pregnant Urinary tract infections Age at onset of diabetes _ Kidney disease Diabetes control good poor Hepatitis Polycystic ovarian syndrome Do you have to take (PCOS) antibiotics before dental Problems with anesthesia work Hypertension (high blood AIDS/HIV pressure) High cholesterol or triglycerides Past Surgical History Please list all surgeries and approximate dates (year) Past Hospitalizations Please list all hospitalizations and approximate dates (year) Comorbidities office use only Page 1 of 7
Review of Symptoms General Infection Fevers HIV Sweats AIDS contact Fatigue TB exposure Loss of appetite Swollen glands Bloody sputum Recurring infections Persistent cough Skin infections Skin Exercise Limitations Rash Mild Acne Moderate Skin cancer Severe Senses Pain in joints Visual problems Back Hearing problems Hips Ear ringing Knees Neurological Feet Dizziness Arthritis Migraines Where? Frequent headaches Gastrointestinal Seizures Heartburn/acid reflux Strokes Stomach pains Memory loss Stomach ulcers Shaking Gastritis Numbness H. pylori infection Uncoordination Rectal bleeding Genito-urinary Liver disease Blood in urine Hepatitis or cirrhosis Vaginal infections Colitis or enteritis Stress urinary incontinence Frequent diarrhea Bladder/kidney infections Frequent constipation Prostate infections Crohn s disease Sleep apnea Stomach surgery Snoring Physical limitations Require C-pap Climbing stairs Daytime drowsiness Unusual fatigue Frequent waking at night Airline travel Choking at night Lifting from floor # of pillows used _ Use of public seating Pulmonary disease Personal care Short of breath on exertion Tying shoelaces Hay fever Playing with children Emphysema/COPD Pneumonia Gynecological (females only) Asthma Last menstrual period Aspiration/choking Pregnancies Current contraception Any chance you are currently pregnant Intending pregnancy in the next 2 years Page 2 of 7
Review of Symptoms (continued) Cardiovascular Psychological Heart attack Depression Congestive heart failure Feeling down Thrombophlebitis Suicidal episodes Swelling of ankles Mood swings for days at a Chest pain time Coronary heart disease Hospitalized for psychiatric Varicose veins reasons Heart murmur Use alcohol or drugs to Pulmonary embolism cope Stroke Hospitalized for substance Ever taken Fen-Phen abuse Have you had an Eating disorder echocardiogram? Vomiting to lose weight Fasting to lose weight Laxatives to lose weight Life more stable than a Medications year ago History of sexual abuse Psychiatric medications in past or present Overeat in reaction to feelings List all daily medications including over-the-counter medications and vitamins, herbs or supplements, and contraceptives Name Dosage Frequency Reason yes yes yes no no no Do you take any of the following over-the-counter medications regularly? Aspirin NSAIDS Ibuprofen Insulin Aleve Steroids yes No Page 3 of 7
Allergies List any known allergies or sensitivities Medication Allergy Reaction Latex Dye Iodine Tape Reaction List any allergies and sensitive to the following: allergies: Social History Marital status Single Married/Partnered Divorced/Separated Widowed Religious preference Ethnic background Education Number of people living in your home Who? What type of work do you do? What type of hobbies or activities do you do? _ Do you currently smoke? Do you drink alcohol? Have you ever smoked more than 100 Drinks per day cigarettes? How often Age started Do you use controlled Age last smoked substances? Average cigarettes per day How often Total years smoking How does your spouse, partner, family, friends, and significant others feel about your weight loss surgery? _ For adolescents only Highest grade in school GPA School performance Excellent Very good Good Fair Poor School name: History of frequent school absence Are you sexually active? Do you smoke marijuana Do you take street drugs Page 4 of 7
Family Medical History Please indicate if you have a family history of the following: Parent Sibling or Child Relatives cousins, aunts, grandparents, etc No Family History Don t Know Diabetes Heart Disease Hypertension Gallstones Obesity Sleep Apnea Asthma Cancer (specify type) Depression High Cholesterol Osteoporosis Age you first became overweight Weight Loss History Weight comfortably maintained Highest adult weight Lowest adult weight Please circle all that apply Grew up: overweight normal weight active in sports under wt. average wt. Weight gain after: pregnancy marriage divorce separation quit smoking moved desk job injury gradual Body For Life/Bill Phillips Gloria Marshall Health spa High protein Hypnosis Low carbohydrate Low fat Calorie counting on my own Gym membership Home gym equipment Please check all that apply. Non-Supervised Attempts Atkins Diet AYDS Mayo Clinic Diet Pritikin Richard Simmons Scarsdale Diet Stillman Diet Sugar Busters Slim Fast South Beach Diet Page 5 of 7
Diet Pills From MD Diet Shots From MD Diet Center Overeaters Anonymous Optifast Weight Watchers Health Management Resources (HMR) Nutri-System T.O.P.S. Jenny Craig New Direction National Weight Loss Acutrim Adipex-P Amphetamines Anorex Benzphetamine Dexatrim Didrex Fastin Fenfluramine Herbal Remedies Ionamin Mazanor Meridia Metabolife Gastric bypass (RNY or other) Stomach stapling Vertical banded gastroplasty Supervised Weight Loss Attempts Weight Loss Medications Supervised Calorie Counting Acupuncture Psychological Counseling Weigh Of Life Weight Loss Center Exercise Counseling Medifast Metrical Nutritional counseling Personal Trainer Obalan Orlistat Phendiet Phentermine Phentrol Plegine Pondimin Redux Sanorex Tepanol Tenuate Wehless Xenical Previous Weight Loss Surgery Gastric band Page 6 of 7
Nutrition History How many meals do you eat daily _ Do you snack between meals Do you drink soda Diet Regular How many sodas do you drink daily _ Food Preferences Candy Fast food Cookies Seafood Fried food Cakes or pies Pizza Vegetables Chocolate Steak or red meat Chips and snacks Dairy products yes No Food allergies TYPICAL DAILY INTAKE Before breakfast PLEASE RECORD THE TYPICAL TYPES OF FOODS AND THE AMOUNTS YOU EAT ON A REGULAR BASIS. Breakfast Morning break Lunch Afternoon snack Dinner After dinner Before bed Page 7 of 7