Medical Weight Loss Questionnaire-EDIT

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Medical Weight Loss Patient Health Questionnaire Medical Spa Date: Name: The information requested in this questionnaire is very important. Tlo give you the best care we must have complete answers. Please be thorough. Weight History lbs What has been your heaviest weight? lbs What is the least you have ever weighed as an adult? When? In your own words, please describe what you hope to accomplish and how you believe your life will be changed by losing weight: Dietary History Approximate age when you first seriously dieted: List the diets and diet programs you have tried: Program Yes No Dates Duration MD Supervised? Jenny Craig Nutri-Systems Weight Watchers OptiFast Medi Fast Fen/Phen Phentermine Meridia Atkins Diet Metabolife O. A. List any physician-supervised and documented weight loss attempt: List any other diets and/or weight loss methods you’ve tried: Patient Health History Questionnaire - Page 1 of 6 Max Loss

Name: Date: Dietary / Eating Patterns Who does the shopping at home? Who does the cooking at home? How many meals do you eat per day? How many meals do you eat per week outside the home? Do you like carbohydrates (starches and sweets) more than other foods? Activity / Excercise To what extent do you enjoy activity/excercise? Area/Methods Utilized: Health Club Not at all Home Slightly Outdoors Pool Moderately Greatly Walking Jogging Sports: Method of Exercise: Aerobic/Endurance Training: Yes No Resistance Training: Frequency per week: Yes No Duration per day: Activity/Exercise in the past: Yes No What kinds of activity: Weight Related Illnesses Have you had, or do you have, any of the following illnesses or symptoms? 1. Heart Disease? Yes No If Yes: Year Diagnosed Do you have, or have you had: Angina CABG (coronary artery bypass graft) Stress test to rule out cardiac problems 2. High Colestorol? Yes No Yes No If Yes: Year Diagnosed List medications: 3. High Blood Pressure? If Yes: Year Diagnosed List medications: Patient Health History Questionnaire - Page 2 of 6 M.I. (myocardial infarction) Abnormal EKG Palpitations High Triglycerides? Yes No

Name: Date: Yes 4. Diabetes? No If Yes: Year Diagnosed - Gestational? Yes No - Neuropathy? Yes No - Controlled with: Diet Oral Medication (list) - Last fasting blood sugar 5. Asthma? Yes If Yes: Year Diagnosed No - ER visits last 2 years? - Hospitalizations last 2 years? - Steroids last 2 years? 6. Shortness of breath? If Yes: Can walk -Stairs Yes Yes No No Blocks Flights Yes No - Morning headaches? Yes No - Restless sleep? Yes No - Awakenings at night? Yes No - Daytime drowsiness? Yes No - Snoring? Yes No - Observed apneas? Yes No 8. Sleep Apnea Syndrome? Yes 7. Trouble Sleeping? No If Yes: Year Diagnosed Last Sleep Study Month/Year CPAP Used? Yes No 9. Heartburn/esophagitis/hiatus hernia? Yes No If Yes: Year Diagnosed Upper UGI Series? Yes No Yes No 10. Belching up acid or sour fluid? Yes No 11. Coughing or choking at night? Yes No 12. Gallbladder disease? Yes No Endoscopy? Medications: Frequency of Use: If Yes: How was it diagnosed? Ultrasound 13. Leakage of urine with laughing/coughing/sneezing? If Yes: Wear pads frequently? Yes Patient Health History Questionnaire - Page 3 of 6 No Physical Exam Yes No

Name: Date: 14. Low back strain/Pain/Sciatica? Yes No If Yes: Seen by Chiropractor? Yes No Seen by Family doctor? Yes No Orthopedic Surgeon? Yes Medications Taken: 15. Pain in Hips/Knees/Ankles?Feet? Yes No No If Yes: Seen by Chiropractor? Yes No Seen by Family doctor? Yes No Orthopedic Surgeon? Yes Medications Taken: No 16. Weight related injuries and trauma: Yes 17. Venous Stasis Disease? If Yes: Do you have Edema? No Yes No Yes No Yes No Yes Scaly & Thick Skin? Leg Ulcers? 18. Gout? Yes If Yes: Gouty Arthritis? Medications Taken: No No 19. History of deep vein thrombosis (DVT), blood clots or pulmonary embolus? Family History? Yes Yes No No Allergies Allergic to any medications? Yes No If yes, please list medication and reaction: Current Medications Please list below all medications you currently use: Medication Patient Health History Questionnaire - Page 4 of 6 Dose and Frequency

Name: Date: System Review Please select all symptoms you currently experience, or have experienced in the past. Feel free to add any additional problems or information. 1. HEAD, EYE, EAR, NOSE & THROAT: Nasal Discharge Hay Fever Sinus Trouble Earache Headache Blurry Vision Haloes Around Lights Loss of Night Vision Ringing In Ears Discharge From Ear Loss of Hearing Dizziness Pain in Swallowing Loss of Balance Sore Throat Lump in Throat Trouble Swallowing Vertigo Hoarseness None of the Above 2. RESPIRATORY: Cough Wheezing Shortness of Breath Use of Two Pillows Coughing Up Blood Out of Breath with Exertion Wake Up at Night/Shortness of Breath Wake Up at Night/Coughing or Choking Asthma Emphysema Bronchitis None of the Above 3. CARDIOVASCULAR: Palpitations Pounding Heart Skipping Heartbeat Pains in Chest Pains in Neck Heart Attack (History of AMI) Heart Murmur Abnormal Electrocardiogram High Blood Pressure Pain in Legs Cold Feet Blue Toes None of the Above 4. GASTROINTESTINAL: Heartburn Nausea Vomiting Food Sticking in Chest Burning in Stomach Diarrhea Blood in Stools Hemorrhoids Fissures Gassiness Bowel Movement Frequency None of the Above Choking on Food Constipation Pain with Bowel Movement Irritable Bowel Syndrome Colitis 5. GENITORURINARY: Pain with Urination Changes in Urinary Habits Small Urine Stream Blood in Urine Kidney Stones Bladder Stones Kidney Failure Nephritis Urinary Tract Infections Frequent Urination Getting Up Late at Nigh to Urinate Leakage of Urine with Cough or Sneeze None of the Above 6. ENDOCRINE (GLANDULAR): Low Thyroid Hyperthyroid Tumor Frequent Flushing Frequent Heavy Sweating 7. MUSCULOSKELETAL: Pain in Joints Swelling of Joints Low Back Pain Hip Pain Knee Pain Ankle Pain Sciatica Limited Joint Motion None of the Above 8. NEUROLOGICAL: Numbness Tingling Convulsions None of the Above Goiter Diabetes None of the Above Arthritis Foot Pain Weakness of any Muscles 9. PSYCHOLOGICAL: Nervousness Anxiety Depression Hospitalization for Emotional Problems Psychiatric Treatment Memory Problems Mood Changes None of the Above Adrenal Gland Broken Bones Sprains Flat Feet Herniated Disk Twitching of Muscles Fainting Thoughts of Suicide Suicide Attempts Psychological Counseling 10. REPRODUCTIVE (Females): Premenstrual Mood Swings Inability to Conceive Hormone Replacement History of Ovarian Cysts Menopause Abnormal Regular Pap Smears Abnormal Pap Smears Mammogram None of the Above Patient Health History Questionnaire - Page 5 of 6

Name: Date: How would you describe your general mood and emotions? Present or past history of eating disorders? Yes No Anorexia (fear of weight gain leading to malnutrition and usually excessive weight loss) Yes No Bulimia (overeating followed by vomiting, laxative/diuretic abuse and/or excessive exercise) Yes No Binge Eating Disorder (consuing a large quantity of food in a short period of time) Yes No Night Eating Disorder (eating very late at night/waking up in the middle of the night to eat If you have answered YES to any of the above: Yes No Have you been in treatment for the disorder? Yes No Do you believe you still have problems with the disorder? What type of medication or treatment plans have you completed related to eating disroders? The above information is true and correct to the best of my belief. I understand the accuracy of this information is important and may affect medical outcomes. Patient Name Date Reviewed: Patient Health History Questionnaire - Page 6 of 6

Weight History Dietary History The information requested in this questionnaire is very important. Tlo give you the best care we must have complete answers. Please be thorough. List any physician-supervised and documented weight loss attempt: List any other diets and/or weight loss methods you've tried: Medical Spa Medical Weight Loss

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