Medical History Form



History & Physical- Metabolic Weight Rehabilitation 8/6/18

Name: Age: Sex: M F Date:_______

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Part I Nutrition Evaluation:

1. Present Weight: Height (no shoes): Desired Weight:

2. What is the main reason for your decision to lose weight?

3. When did you begin gaining excess weight? (Give reasons, if known):

4. How many times a week do you eat out?

5. What restaurants do you frequent?

6. Who plans meals? Cooks? Shops?___________

Do you buy conventional or organic products? __________________________

7. Food allergies:

8. Food cravings:

9. Any specific time of the day do you crave food?

10. Do you drink coffee or tea? Yes No How much daily?

11. Do you drink cola drinks? Yes No How much daily?

12. Do you drink alcohol? Yes No What? How much daily?

Weekly?

13. What sugar substitute do you use? Butter? Margarine?

14. Do you awaken hungry during the night? Yes No

What do you do?

15. Typical Breakfast Typical Lunch Typical Dinner

Time eaten: Time eaten: Time eaten:

Snack Habits:

What? How much? When?

16. When you are under a stressful situation at work or family related, do you tend to eat more? Explain: ________________

17.Describe your usual energy level: ) none 1 2 3 4 5 6 7 8 9 10 (highest)

Any comment about energy?____________________________________________

Part II GI Assessment

1. Do you currently have any GI symptoms:

a. Gas/belching/bloating _____ right after a meal ___ or several hours later ___

b. Reflux _____

c. Abdominal discomfort ____

d. Diarrhea ____

e. Constipation _____

2. History of:

f. Crohn’s Disease, Colitis, or Celiac Disease? ________

g. Gall Bladder removal _________________

h. Abdominal surgery: ___________________________

3. Do you take a proton pump inhibitor such as: omeprazole (Prilosec), lansoprazole (Prevacid), dexlansoprazole (Dexilent), rabeprazole (Aciphex) or pantoprazole (Protonix)

4. Do you have a history of foreign travel?__________________________

Part III Hormone Assessment

1. Do you currently have any of the following symptoms? Check if “yes:”

a. Cold intolerance ___ e. Weight gain ___

b. Constipation ___ f. Joint pain ___

c. Dry skin ___ g. Depression ___

d. Brittle hair ___ h. Fatigue ___

2. Are you currently on thyroid medication? ____ If “yes” which one and current dose:____________________________

3. Are you currently on hormone replacement therapy (estrogen, progesterone,

testosterone, DHEA): _______________________________________________

4. Are you on any glucose-lowering medication or supplements? _______________

Part IV Stress Assessment

1. What are your current stress-related demands? ____________________________________________________________________________________________________________________________________________

2. What do you do to manage stress? ___________________________________________

Part V Sleep Assessment

1. Do you work the night shift? ________________

2. How many hours of sleep do you typically get? ___ Do you feel refreshed when you wake up? _____

3. Do you use and sleep aids (ie. medication)? ____________________________

4. Do you snore? _______Do you have a history of sleep apnea? ____ Use CPAP? ______

Part VI Focal Infection Assessment

1. Have you had any: root canals? _____ history of gingivitis?_________

bad breath? __________

2. Have you ever had an Epstein Barr viral infection (infectious mono)? ____

3. Do you have a history of candida (yeast) infections?______________

4. Any other significant infection?_________________________________

Part VII Toxic Exposure Assessment

1. Do you have mercury dental fillings? ___________

2. What type of fish do you eat? _________________

3. What is your occupation and possible exposures at work? _____________

4. Have you been exposed to wet buildings? __________________________

5. Are you taking any Statins? _____. If “yes” for how long? ____ Do you have any of the following while on statins: muscle aches, mood changes, memory loss? ______

6. Do you take any non-steroidal anti-inflammatory medication (NSAIDs)? ________

Part VIII Activity Assessment

1. Activity Level: (answer only one)

___ Inactive(no regular physical activity with a sit-down job.

Light activity(no organized physical activity during leisure time.

Moderate activity(occasionally do activities such as weekend golf, tennis, cycling,

jogging, or swimming.

____Heavy activity: lifting, stair climbing, heavy construction, etc., or regular participation in jogging, swimming, cycling or active sports at least 3 times per week.

Vigorous activity: extensive physical exercise for at least 60 minutes per session 4 times per week.

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.

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Exercise

Stress

Dietary

Habits

Weight

Management

Hormone

Balance

Focal Infection

Sleep

Toxic Exposures

Gut Dysbiosis

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