Evaluation of Weight Related Medical Conditions
NEW PATIENT MEDICAL HISTORY FORMName: (First)______________________________ (Last) ______________________________ (MI)____Date of Birth:_____/_____/__________Date of Visit: _____/_____/__________Phone:(Home/Cell)_______________________(Work)_______________________Gender: M / FReferred By:______________________________How does your weight is affect your life andhealth?_______________________________________________________________________________________________________________________________________________________________________________________________________________Weight HistoryWhen did you first notice that you were gaining weight? Childhood Teens Adulthood PregnancyMenopauseDid you ever gain more than 20 pounds in less than 3 months? Y / N If so, when?_________How much did you weigh: one year ago? _____Five years ago? _____ 10 years ago? _____Life events associated withweight gain (check all that apply):MarriageDivorce Pregnancy Abuse IllnessTravelInjuryNightshift work Job change Quitting smoking Alcohol DrugsMedication(please list: ______________________________________________________________)Previous weight-loss programs (check all that apply): Weight WatchersNutrisystemJenny CraigLA Weight LossAtkins South BeachZone dietMedifastDash diet Paleo diet HCG diet Mediterranean dietOrnish dietOther: _______________________What was your maximum weight loss?____________________________________________________What are your greatest challenges with dieting? ________________________________________________________________________________________________________________________________Have you ever taken medication to lose weight? (check all that apply): Phentermine(Adipex)MeridiaXenecal/AlliPhen/Fen Phendimetrazine(Bontril)TopamaxSaxendaDiethylpropionBupropion(Wellbutrin)BelviqQsymiaContraveOther (including supplements):__________________________________________________________What worked? _______________________________________________________________________What didn’t work? ____________________________________________________________________Why or why not? _____________________________________________________________________Nutritional HistoryHow often do you eat breakfast?_____ days per week at _____:_____ a.m.Number of times you eat per day:_____ What beverages do you drink?__________________________Do you get up at night to eat? Y / N If so, how often?_____ timesList any food intolerances/restrictions: _____________________________________________________Food triggers (check all that apply):StressBoredomAnger Insomnia Seeking rewardPartiesEating outOther: _______________________Food cravings:SugarChocolateStarchesSalty Fast food High fatLargeportionsFavorite foods: _______________________________________________________________________Medical HistoryExercise type: ________________________________________________________________________Duration:_____ hours _____ minutes Number of times per week: _____Does anything limit you from exercising? ___________________________________________________How many hours do you sleep per night? _____Do you feel rested in the morning? _____Past medical history (check all that apply):Heart attackAnginaGallbladder stonesSleep apneaHigh blood pressureStrokeIndigestion/reflux ThyroidHigh cholesterolDiabetesCeliac diseaseAnxietyHigh triglyceridesGout PancreatitisDepressionInfertility Arthritis Polycystic Ovarian Syndrome Bipolar GlaucomaCancer (type/s): ____________________________________________Have you ever been diagnosed with an eating disorder? Y / N If yes, which one? _________________Past surgical history (check all that apply): Gastric bypassGastric bandingGastric sleeveGallbladderHeart bypassHysterectomyOther:_________________________________________________________Medications (list all current medications,including over-the-counter medications, supplements, and herbs):____________________ ________________________________________ ____________________ ________________________________________________________________________________Allergies: (Medications)________________________________________________________________________(Food)______________________________________________________________________________Social HistorySmoking:NeverCurrent smoker (_____ packs/day)Past smoker (quit _____ years ago)Alcohol: Never OccasionalRegularly(_____drinks per day)Prior treatment for alcoholism? Y / NDrugs:Never Current PastType of drugs:______________________Marijuana:NeverCurrent user (_____ times/day)Family HistoryObesity (check all that apply): MotherFatherSisterBrother DaughterSonDiabetes(check all that apply):Mother Father Sister Brother DaughterSonOther (check all that apply): High blood pressure Heart diseaseHigh cholesterol High triglyceridesStrokeThyroid problemsAnxietyDepression Bipolar disorderAlcoholismCancer (type/s): _______________________________________ Other:_______________________Gynecologic HistoryAge periods started? _____ Age periods ended _____Periods are: Regular / Irregular Heavy / Normal / LightNumber of pregnancies: _____ Number of children:_____Age of first pregnancy: _____ Age of last pregnancy: _____System Review (Check all that apply)Recent weight loss more than 10 poundsRecent weight gain more than 10 poundsAcneSkin rashCoughSnoringShortness of breathChest painDifficulty breathing when flatFainting/Blacking outPalpitationsSwelling ankles/extremitiesAbdominal painBloatingConstipationDiarrhea Food intoleranceDysphagia/difficulty swallowingIndigestionNausea/vomiting Increased appetite Decreased appetite Heartburn Gas and bloating Urinary frequency/urgency Slow urine flow Nighttime urination Blood in stools Back pain (upper) Back pain (lower) Joint pain Muscle aches/pain Dizziness Headaches Seizures Weakness/low energy Anxiety Depression Insomnia Memory loss Inability to concentrate Mood changes Nervousness Loss of interest Cold intolerance Excessive sweating Hair changes Heat intolerance Blood clots Fatigue/tiredness(Women only) Absence of periodsHot flashes Change in bladder habits Abnormal/excessive menstruation Facial hairComments: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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