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Patient Medical History for Weight Loss Program

Tell Us About Yourself

Your Health

Are you in good health at the present time to the best of your knowledge?
Are you under a doctor's care at the present time?
Are you taking any medications at the present time?
Please list names and dosages
Please list all products including pain relief, vitamins, supplements, etc.
Do you have any allergies to medications?
If answer to above question is yes, please list those medications and your reaction.
If answer to previous question is Yes, at what age was the onset?
History of Heart Attack or Chest Pain or other heart condition?
If answer to previous question was Yes, please list medications taken for headaches:
Difficulty in Bowel Movements

Gynecologic History

Onset
How long does it last?
If taking HRT and answering yes to previous question, please tell us the type
If using Birth Control and you answered yes to the previous question, please tell us what kind

Illness and Surgical History

Please list any injuries you may have had and the dates they occurred
Please list any surgeries you've had and the dates they occurred

Family History

If Deceased
 
If Deceased
 
If Deceased
 
If Deceased<br/>
 
Please specify which relative and the condition

Past Medical History

If you checked 'Other' on the previous question, please tell us about it

Nutrition Evaluation

(without shoes)
In what time frame would you like to be your desired height?
What is the main reason for your decision to lose weight?
When did you begin gaining excess weight? (Give reasons, if known)
What has been your maximum weight (non-pregnant) and when?
Give dates and results of your weight loss on previous diet plans you have followed
Is you spouse, fiance, partner overweight?
By how much is he/she overweight?

Eating Habits

How often do you eat out?
What restaurants do you frequent?
How often do you eat "fast foods"?
Who plans meals?
Who cooks meals?
Who shops for your meals?
Do you use a shopping list?
What time of the day on on what day do you usually shop for groceries?
Please specify if you have food allergies and what reaction you experience
Please specify any food dislikes you have
Please specify any foods you crave
Any specific time of the day or month you crave food?
Do you drink coffee or tea?
How much coffee or tea daily?
Do you drink cola drinks?
How much soft drinks daily?
How much alcohol daily?
What kind? How much daily or weekly?
Do you awaken hungry during the night?
How do you satisfy your nighttime hunger?
What are your worst food habits?
What do you snack on? How much? and When?
When ou are under a stressful situation at work or family related, do you tend to eat more? Explain.
Do you think you are currently undergoing a stressful situation or an emotional upset? Explain.
Answer only one
Please describe your typical breakfast<br/>At what time do you eat breakfast?
Please describe your typical lunch<br/>At what time do you eat lunch?
Please describe your typical dinner.<br/>At what time do you eat dinner?
Where and with whom do you eat Breakfast?<br/>Lunch?<br/>Dinner?

Describe your activity

Describe your usual energy level
Answer only one
Answer only one
Please describe your general health goals and improvements you wish to make

This information will assist us in assessing your particular problem areas and establishing your medical management. thank you for your time and patience in completing this form. Please also complete the "12 Reasons Why I Want To Reach My Goal Weight" form.

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