Pg 1 Weight Loss Center - Cloudinary

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Pg 1Weight Loss CenterName:Gender:DOB:Social Security#Drivers License #Marital Status:Race:Address:Religion:City:Home phone:OK to leave message?YesNoCell/work:OK to leave message?YesNoOccupation:Zip:Employer:Emergency Contact:Phone Number:Relationship:My medical information can be discussed with:Patient OnlyFamily member or friend (listname and relationship):May we contact you by email regarding your progress in theprogram?May we keep you informed of program updates, special speakersand events via our email newsletter (sent monthly)Note: If you answer "yes", you may notify us at any time to be removed from the mailing listEmail address:YesNoYesNoInsurance Information:Primary Insurance Co.Subscriber Name:DOB:ID#Group #Health Plan:PPOPOSHMO - Medical Group:Secondary Insurance Co.Subscriber Name:DOB:ID#Group #Health Plan:PPOPOSHMO - Medical Group:Assignment of BenefitsI, the undersigned, have insurance coverage withand assign directly toStanford Health Care - ValleyCare any medical benefits, if any, otherwise payable to me for services rendered. Iunderstand that I am financially responsible for all charges (nurse practitioner and dietitian appointments andeducation) whether or not paid by insurance. I hereby authorize the doctor to release all information necessary tosecure the payment benefits.Patient Signature:Electronic signatureDate:

Pg 2Date:Name:DOB:GenderWeight Loss CenterPatient History & Lifestyle QuestionnaireAge:Please answer each question to the best of your ability. Then mail/mail/fax a completed copy to the Weight Loss Center prior toyour appointment (5725 W. Las Positas Blvd Suite 220 Pleasanton, CA 94588 or fax 925-416-6722). It is very important that wehave adequate information to prepare for your visit, so if we do not receive your questionnaire in advance, your appointmentmay need to be rescheduled.Primary Care Physician:PCP Address:PCP Phone Number:PCP Fax:Reason for Consultation:WEIGHT HISTORYHeight:Current Wt (lbs):Approximate wt 5 years ago:1 year ago:When did you become overweight/obese?Lowest adult weight (lbs)?Highest adult weight (lbs)?Desired goal weight (lbs)?Are there any specific triggers that have caused you to gain weight?PregnancyMedicationStopped smokingMovingInjury or activity changeJob changeDivorceEmotional IssuesOther:WEIGHT LOSS PROGRAMS/DIETS/MEDICATIONSMethod of Weight LossWeight WatchersOver the counter diet pillsJenny CraigNutri SystemLow Carb/South Beach/AtkinsDiet program supervised by doctorDiet supervised by Dietitian orHospitalWt Loss SurgRx Wt Loss MedLiquid fastOther:YESNOWhen?Duration (How long?) Max Weight Loss

Pg 3NameMEDICAL HISTORYHave you had any of the following obesity-related problems?Diabetes MellitusYesNoHeartburn/GERDYesNoHigh Blood PressureYesNoHigh CholesterolYesNoJoint pain/ArthritisYesNoSleep ApneaYesNoYesNoYesNoUsing CPAP or BiPAP?Is it working?OtherSURGERIES and HOSPITALIZATIONSDATEProcedure/Surgery or Reason for hospitalizationANESTHESIAPlease list any problems/complications you have had with anesthesia:Hospital

Date:Name:Phone Number:DOB:Height:Primary Care Provider:PCP Phone Number:Current Wt (lbs):Pharmacy phone number:Pharmacy:MEDICATIONSMedication Allergies?If yes, please list allergies with reaction:OTHER ALLERGIES:Surgical Tape?Latex?Iodine?PRESCRIPTION MEDICATIONS(Add below or attach typed list. Please include over the counter medications.)MedicationEXAMPLE: AtenololStrength50mgVitamins/Herbal/Nutritional SupplementsNameStrengthMedicationHow you take itOnce DailyHow you take itNO MEDICATIONSReasonHigh blood pressureReasonPg 4

Pg 5NameMEDICAL HISTORYHave you recently had any of the following?Physical ExamYesNoIf yes, date:Doctor's Phone NumberWhere/Doctor's NameBlood TestYesIf yes, date:NoDoctor's Phone Number:Where/Doctor's Name:Have you EVER had any of the following?EKGYesIf yes, date:NoDoctor's Phone Number:Where/Doctor's Name:EchocardiogramYesIf yes, date:NoDoctor's Phone Number:Where/Doctor's Name:Cardiac StressTestYesNoIf yes, date:Doctor's Phone Number:Where/Doctor's Name:AngiogramYesNoIf yes, date:Doctor's Phone Number:Where/Doctor's Name:Upper EndoscopyYesNoIf yes, date:Doctor's Phone Numbe:rWhere/Doctor's Name:ColonoscopyYesIf yes, date:NoDoctor's Phone Number:Where/Doctor's Name:Sleep StudyYesIf yes, date:NoDoctor's Phone Number:Where/Doctor's Name:Diabetes EducationYesNoIf yes, when and how many visits?Doctor's Phone Number:Where/Ordering Doctor?LIFESTYLE CHOICES/HABITSAverage number hours you sleep/night:Do you smoke now?Is this enough for you?If yes, how many packs/day:Have you ever smoked?If yes, age started:Have you ever used any recreational/illegal drugs (i.e. marijuana)?Currently?Explain:Age quit:

Pg 6Name:Approximately how much of each of the following beverages do you consume?Beer12 oz cans/wkTea w/caffeinecups/dayWatercups/dayWine4 oz glasses/wkCoffee w/caffeinecups/dayRegular Sodacans/dayLiquor2 oz. drinks/wkMilkcups/dayDiet Sodacans/dayJuicecups/dayOther beverage choices:Personal Medical History/Review of Systems: Please check all that apply.CONSTITUTIONALGood general healthCARDIOVASCULAR entUnexplained weightchangeFeverEYESChest pain or anginapectorisMurmursBlood clotPalpitations/racingheartShortness of breathwith walking or lyingflatSwelling of feet,ankles, or handsDisease or sentBlurred/double uent PresentNeverPastPresentHearing loss/ringingNeverPastPresentEaraches or drainageNeverPastPresentNeverPastPresentBurning or painfulurinationIncontinence ordribblingChange in force ofstream urinatingBlood in urineNeverPastPresentKidney InfectionNeverPastPresentNose bleedsNeverPastPresentKidney stonesNeverPastPresentMouth soresNeverPastPresentSexual difficultyNeverPastPresentBleeding tPresentTesticular ntEARS/NOSE/MOUTH/THROATChronic sinusproblemsChronic rhinitisBad breath or badtasteSore throat or voicechangeSwollen glands inneckCARDIOVASCULARHigh cholesterolNeverPastPresentHeart tINTEGUMENTARY (skin, breast)Rash or itchingNeverPastPresentChange in skin entNeverPastPresentBreast painNeverPastPresentBreast lumpNeverPastPresentBreast dischargeNeverPastPresentChange in hair ornailsSuspicious moles orspotsVaricose veins

Pg 7NameRESPIRATORYMUSCULOSKELETAL (CONT.)Chronic or frequentcoughCoughing/choking atnightSpitting up entWeakness of musclesor jointsMuscle pain orcrampsBack painShortness of breathNeverPastPresentAsthma or wheezingNeverPastPresentDaytime sleepinessNeverPastPresentLung tGASTROINTESTINALColitis: IrritableBowel SyndromeCrohn's Disease orUlcerative ColitisGallbladder Disease/GallstonesChange in bowelmovementsPainful tPresentNeverPastPresentDifficulty walkingNeverPastPresentCold extremitiesNeverPastPresentENDOCRINEGlandular orhormonal astPresentNeverPastPresentFrequent diarrheaNeverPastPresentRectal resentLoss of appetiteNeverPastPresentSlow to heal aftercutsBleeding or bruisingtendencyAnemiaHeartburn or PastPresentAbdominal painNeverPastPresentHepatitis: liverdiseaseNeverPastPresentBlood in or tarrystoolsNausea/VomitingPeptic ulcer(stomach/duodenal)Hiatal herniaMUSCULOSKELETALJoint painJoint stiffness everPastPresentNeverPastPresentDiabetesDiet controlledControlled by oralmedicationControlled by insulinExcessive thirst orurinationHeat or coldintoleranceDry skinHEMATOLOGIC/LYMPHATICPast bloodtransfusionEnlarged d or PresentParalysisNeverPastPresentHead injuryNeverPastPresentSeizuresNumb or tinglingsensationsTremors

Pg 8Name:PSYCHIATRICMemory loss orconfusionAnxiety/Nervous/Panic everPastPresentIodine, methiolate,other antisepticOther drugs/medicationsFEMALES ONLY:Bipolar her:NeverPastPastPresentNeverPastPresentPain with periodsNeverPastPresentVaginal dischargeNeverPastPresentIrregular periodsNeverPastPresentForm of birth control if verPresentTaking hormone replacement?Food Allergy to:Number of pregnancies:Skin reaction or other negative reaction to:Penicillin or otherantibioticsMorphine, Demerol,other narcoticsNovocaine or otheranestheticsAspirin or other painremediesTetanus antitoxins orother serumsLive births:Date of last menstrual esentNeverPastPresentNeverPastPresentDate of last pap smear/pelvic exam:Date of last mammogram:Ordering physician:Physician Phone Number:Physician address:FAMILY MEDICAL HISTORYPlease indicate which, if any, of your family members have or had the following:SiblingAnemiaBleeding problemsBlood clotsCancer (breast)Cancer (colon)Cancer (other)DiabetesGallstonesGoutHeart DiseaseHigh blood pressureKidney diseaseObesitySleep ApneaStrokeMotherFatherGrandparentAunt/Uncle

Pg 9Name:Is your father living?If not, cause/age of death:Is your mother living?If not, cause/age of death:Are any family members obese? Please list obeserelatives (i.e. father, aunt) and approximate weights.DIET AND EXERCISE HABITSWith whom do you typically eat?AloneFamilyOther (explain):Who typically does the food shopping for your household?Who usually prepares the food you eat at home?Are you confident that you can effectively read food labels to select nutritious food?YesNoPlease list any food allergies or intolerances:Have you ever been a binge eater?No Do you sometimes binge now?YesHave you ever purged (vomited on purpose) after eating too much?Do you do this now?YesNoYesStructured eaterNoExplain:Do you ever get up after going to bed to have something to eat?Are you a more:Yeshaphazard eaterYesNoExplain:What eating habits do you have that botheryou or contribute to your weight problem?Briefly describe a "typical" day's food intake:Breakfast:Lunch:Dinner:Snacks:Please select the best answer for each question about your typical food habits:1. How often do you eat three meals in a day (breakfast, lunch and dinner)?AlwaysSome daysMost daysRarely/NeverDinnerNone skipped usually2. Which meal is most often skipped?BreakfastWhy?LunchNoFrequency:

Pg 10Name:3. How often do you "snack" (defined as any food eaten between meals or after dinner)?Rarely or neveronce/day2-3 times/dayOften graze on food throughout the day4. How often do you crave sweets (candy, cookies, donuts, pastries, etc.)? 3 times/week3-5 times/weekonce/day2 or more times/day5. How frequently do you eat until very full or uncomfortable?most mealsoftenoccasionallyRarely/NeverWhat is most likely to prompt you to overeat?6. How often do you typically eat in restaurants? Count breakfasts, lunches, & dinners (do not include fast food/take out food):1 meal/week or less2 meals/week3-4 meals/week5 meals/week or more7. How often do you eat fast food, cafeteria, or take-out meals? Count all breakfasts, lunches and dinners:1 meal/week or less2 meals/week3-4 meals/week5 meals/week or more8. What is your usual fruit and vegetable intake (combined)? 1 serving/day1-2 servings/day3-4 servings/day5 or more servings/day9. Which protein foods do you typically eat? (check all that apply)ChickenFish/shellfishCheese/cottage cheeseMeat/beefEggsSoy/tofu10. How long does it usually take you to eat a meal?1-10 minutes10-20 minutes20-30 minutesAt least 30 minutes11. Which emotions will cause you to eat larger portions, more snacks or choose different foods? (Check all that omHappiness/celebratingOther:EXERCISEAre you a regular exerciser currently? (Includes regular walking)If yes, what type(s) of exercise do you typically do?How many days/week do you exercise?How long each time?Any physical restrictions that keep you from exercising?Explain:GENERAL/SOCIAL HISTORYMarital Status:Partner:Highest Level of Education:Occupation:With whom do you reside?List activities, hobbies, personal interests, etc.Hours/week you work?Number of Children:Ages of children:

Pg 11Name:The following information is extremely important and very confidential. Honesty is needed in order to provideyou with the best possible treatment plan.Do you have a history of abuse? (Please include emotional, physical, mental, substance, orother types of abuse you've dealt with.)If YES, when?NoUnsureYesNoUnsureYesNoUnsureExplain:Have you ever sought treatment for depression, anxiety, panic attacks, bipolar disorder oranother mental health problem?If YES, when?Explain:Have you ever been in treatment wiht a psychologist (therapist)?GroupYesIndividualWhen and for how long?Therapist Phone Number:If YES, please provide therapist's name:Have you ever been in treatment wiht a psychiatrist?YesNoAre you currently receivint treatment?YesNoTherapist Phone Number:If YES, please provide therapist's name:Are you currently taking any psychiatric medications (antidepressant, med for anxiety, etc)?YesNoIf YES, please list medications on page 4 AND provide name and phone of prescribing doctor:Phone Number:Prescriber name:Have you ever been hospitalized for mental health reasons?YesNoExplain:Have you ever been treated for alcohol abuse or chemical dependency?YesNoExplain:Have you ever attended AA or NA meetings?YesNoExplain:Describe your present life stressors:Describe your present support system you rely upon (church,spouse, family, friends, co-workers, etc.):Have you ever intentionally injured yourself?YesNoYesNoYesNoIf so, when and how?Have you ever tried to kill yourself?If so, when and how?Have you ever intentionally injured someone else?If so, when and how?Are you attending now?YesNo

Pg 12Name:OTHER PHYSICIANS (Primary Care doctor should already be listed on page 2Gynecologist Name:Phone Number:Orthopedist Name:Phone Number:Endocrinologist Name:Phone Number:Address:Fax Number:Address:Fax Number::Address:Fax Number::Address:Psychiatrist Name:Phone Number:Fax Number:Address:Psychotherapist Name:Phone Number:Cardiologist Name:Phone Number:Other MD Name/specialty:Phone Number:Patient Signature:Electronic signatureReferral SourceHow did you hear about us?InternetInsurance/Hospital ReferralPatient referralPhysician referralOtherFax Number:Address:Fax Number:Address:Fax Number:

Over the counter diet pills Jenny Craig Nutri System Diet supervised by Dietitian or Hospital Diet program supervised by doctor Liquid fast Other: Wt Loss Surg Rx Wt Loss Med Low Carb/South Beach/Atkins Age: Name SURGERIES and HOSPITALIZATIONS DATE Procedure/Surgery or Reason for hospitalizat

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