Patients form

First name *

Please enter First Name

Last Name *

Please enter Last Name

Date *

Please enter Date

Home Phone: (include area code) *

Please enter Home Number

Cell Phone: (include area code) *

Please enter Cell Phone

Date of Birth - DOB *

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Address *

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City *

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State *

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Zip *

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Occupation *

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Email *

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Sex *

Male

Female

Other

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How Did You Hear About Us?

Primary Care Physician

Do you have any of the following diseases or problems:

Check "N/A" if you Don't Know the answer to the question

Has your doctor advised you to lose weight? *

yes

N/A

Please Select One Option

Do you feel more stressed than usual? *

yes

N/A

Please Select One Option

If so, Please explain:

Are you on medication for anxiety/Depression? *

yes

N/A

Please Select One Option

Do you have any dietary restrictions? *

yes

N/A

Please Select One Option

yes

N/A

Please Select One Option

yes

N/A

Please Select One Option

yes

N/A

Please Select One Option

Family or personal history of thyroid cancer. *

yes

N/A

Please Select One Option

Family or personal history of any other cancers. *

yes

N/A

Please Select One Option

Any other symptoms associated with your chief complaint? *

yes

N/A

Please Select One Option

How does your weight affect your daily life? *

yes

N/A

Please Select One Option

What changed that caused the weight gain (if anything)?

What is the main reason you are seeking treatment at this time?

What is your goal weight or a weight where you felt comfortable?

When was the last time you were at your ideal weight?

How much weight do you want to lose?

Do you diet? If so, How many times a year do you diet?

What motivates you to lose weight?

What is the hardest part about managing your weight?

What challenges do we need to overcome to reach your goal?

What have you tried in the past that has failed? please explain

Do you have any of the following diseases or problems:

Check "N/A" if you Don't Know the answer to the question

yes

N/A

Please Select One Option

I have never tried to lose weight *

yes

N/A

Please Select One Option

Jenny Craig/Nutrisystem *

yes

N/A

Please Select One Option

South Beach/ Atkins diet *

yes

N/A

Please Select One Option

yes

N/A

Please Select One Option

yes

N/A

Please Select One Option

yes

N/A

Please Select One Option

Medically Supervised Treatment: (describe) *

yes

N/A

Please Select One Option

Have you ever taken Phentermine? Yes/ No *

yes

N/A

Please Select One Option

Have you taken any other medications (OTC or prescription) for weight loss? Yes/No *

yes

N/A

Please Select One Option

Have you maintained weight loss for up to a year with any of these programs/treatments? *

yes

N/A

Please Select One Option

Did you have weight problems since your childhood? *

yes

N/A

Please Select One Option

Inches lost

Pounds lost.

Fast weight loss.

Permanent.

How fast do you want to be slim, trim and fit? please explain:

What would stop you from doing a weight loss program?

Do you have any of the following diseases or problems:

Check "N/A" if you Don't Know the answer to the question

yes

N/A

Please Select One Option

Do you suffer from uncontrolled craving? *

yes

N/A

Please Select One Option

Do you feel that food controls you *

yes

N/A

Please Select One Option

Do you eat because of your emotions? *

yes

N/A

Please Select One Option

Do you eat between meals? *

yes

N/A

Please Select One Option

Do you feel that your eating behaviors are normal? *

yes

N/A

Please Select One Option

Does your family support your weight loss effort? *

yes

N/A

Please Select One Option

Light activity- no organized physical activity during leisure time. *

yes

N/A

Please Select One Option

What do you remember most about it?

Briefly describe your eating behaviors and pattern

Light activity- no organized physical activity during leisure time.

Moderate activity- occasionally involved in weekend activities ie golf/tennis/jogging/swimming/cycling at least twice a week.

Heavy Activity- consistent lifting, climbing, heavy construction or regular Participation in jogging, swimming or active sports at least three times a week

Inactive- no regular physical activity/sit down job.

Vigorous Activity- Participation in extensive physical exercise for at least 60 Min per session 4+ times per week

Do you have any of the following diseases or problems:

Check "N/A" if you Don't Know the answer to the question

Is stress a major problem for you? *

yes

N/A

Please Select One Option

Do you feel depressed often? *

yes

N/A

Please Select One Option

Do you panic when stressed? *

yes

N/A

Please Select One Option

Do you have problems with your appetite *

yes

N/A

Please Select One Option

yes

N/A

Please Select One Option

Have you ever attempted suicide? *

yes

N/A

Please Select One Option

Have you ever thought about injuring yourself? *

yes

N/A

Please Select One Option

Do you have difficulty sleeping? *

yes

N/A

Please Select One Option

Have you ever seen a counselor / Therapist? *

yes

N/A

Please Select One Option

If you have ever received in patient treatment for a mental health illness or for substance abuse? *

yes

N/A

Please Select One Option

Weight gain

Weight loss

Fatigue.

Night Sweats

Appetite change.

Sweating.

Glaucoma

Vision loss

Blurred/Double vision

Hearing loss

Nasal congestion

Snoring

Mouth/throat irritation

Tooth problems

Seasonal Allergies

Shortness of Breath

Wheezing

Cough

Chest pain/Pressure

High/Low blood pressure

Heart Racing/Palpitations

Heart attack

Ankle swelling

Sweating

Heart Failure

Syncope/Passing out

Nausea/Vomiting

Difficulty Swallowing

Abdominal Pain

Diarrhea

Blood in Stool

Liver disease

Heartburn

Constipation

Urinary retention

Pain with urination

Incontinence

Frequent UTIs

Sexual problems

Kidney Disease

Urinary hesitancy

Urinary frequency

Muscle Wasting

Arthritis

Pain

Stroke

Insomnia

Headache/Migraine

Dizzy spells/Vertigo

Seizures

Bipolar disorder

Depression/anxiety

ADHD/ADD

Eating Disorders

Change in Sex Drive

Cold or Heat Intolerance

Thyroid Problems

Blood Sugar Problems

Change in Body Hair

Excessive Thirst

Skin Rash

Dry Skin

Eczema

Stroke

Insomnia

Headache/Migraine

Dizzy spells/Vertigo

Seizures

Bipolar disorder

Depression/anxiety

ADHD/ADD

Eating Disorders

Alcoholism

I have not experienced any of the symptoms above

me

family

none

comment

Please Select One Option

Autoimmune Disorders *

Please Select One Option

Diabetes, Type1or2 *

Please Select One Option

Erectile Dysfunction *

Please Select One Option

Diabetes type 1 or 2 *

Please Select One Option

Ringing in ear (tinnitus) *

Please Select One Option

Rheumatoid Arthritis *

Please Select One Option

Health History Form

Do you have any of the following diseases or problems:

Check "N/A" if you Don't Know the answer to the question

Has your doctor advised you to lose weight? *

Do you feel more stressed than usual? *

Are you on medication for anxiety/Depression? *

Do you have any dietary restrictions? *

Breast feeding *

Might be pregnant *

Pregnant *

Family or personal history of thyroid cancer. *

Family or personal history of any other cancers. *

Describe the main reason for your visit today:

Any other symptoms associated with your chief complaint? *

How does your weight affect your daily life? *

Past weight loss programs/plans: (check all that apply)

Do you have any of the following diseases or problems:

Check "N/A" if you Don't Know the answer to the question

Weight Watchers *

I have never tried to lose weight *

Jenny Craig/Nutrisystem *

South Beach/ Atkins diet *

Liquid Diets *

Keto Diet *

Surgery *

Medically Supervised Treatment: (describe) *

Have you ever taken Phentermine? Yes/ No *

Have you taken any other medications (OTC or prescription) for weight loss? Yes/No *

Have you maintained weight loss for up to a year with any of these programs/treatments? *

Did you have weight problems since your childhood? *

Describe your weight as an adult?

What is more important?

Inches lost

Pounds lost.

What is more important?

Fast weight loss.

Permanent.

STEP 1/5

Psychosocial Assessment

Do you have any of the following diseases or problems:

Check "N/A" if you Don't Know the answer to the question

Do you Binge eat? *

Do you suffer from uncontrolled craving? *

Do you feel that food controls you *

Do you eat because of your emotions? *

Do you eat between meals? *

Do you feel that your eating behaviors are normal? *

Does your family support your weight loss effort? *

Light activity- no organized physical activity during leisure time. *

What is your commitment to losing weight: ( please rate): (Low) 1 2 3 4 5 6 7 8 9 10 (High)

Activity Level

Light activity- no organized physical activity during leisure time.

Moderate activity- occasionally involved in weekend activities ie golf/tennis/jogging/swimming/cycling at least twice a week.

Heavy Activity- consistent lifting, climbing, heavy construction or regular Participation in jogging, swimming or active sports at least three times a week

Inactive- no regular physical activity/sit down job.

Vigorous Activity- Participation in extensive physical exercise for at least 60 Min per session 4+ times per week

STEP 2/5

Social History

Do you have any of the following diseases or problems:

Check "N/A" if you Don't Know the answer to the question

Do you smoke? *

Past Smoker? *

Do you use smokeless tobacco? *

PPD skin testing (TB) in the past? *

Do you drink alcohol? *

Caffeine Use *

Do you use recreational drugs such as Cocaine, Marijuana or Methamphetamine? *

STEP 3/5

Medication History

Do you have any of the following diseases or problems:

Check "N/A" if you Don't Know the answer to the question

Are you allergic to any Medication? *

If yes, list the medication and reaction.

Have you been hospitalized or undergone a surgical procedure? Yes/ No *

If yes, please list:

FEMALES ONLY

Have you been through menopause? Yes /No

Have you ever been pregnant? Yes/ No

Are you pregnant or breast feeding? Yes/ No

Last Physical Exam: