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Patient History
Patient Name
First
Last
Weight Loss History
Weight History
Tell me about your weight history (length of time overweight, specific reason?, etc.)
Weight Loss Medications
Have you ever been on weight loss medications? No / Yes-Explain
Pregnancy History
Number of Pregnancies
Number of live children
Current Contraception
Surgical / Hospital History
Surgeries
List any surgeries or operations and your approximate age at the time.
Hospitalizations
List any other hospitalizations, the reason, and your age at the time.
Social History
Smoking
Never
Not now, but Yes in the past
Yes, currently
Smoking Details
How much, and when did you quit?
Smoking Details
How much and for how long?
Alcohol
No
Yes
Alcohol Frequency
Caffeine
No
Yes
Caffeine Details
What kind and how much?
Drug Use
Please describe any illicit drug use.
Family History
Please check if anyone in your immediate family has had or currently has any of these conditions.
Arthritis
Cancer
Chemical Dependency
Diabetes
Heart Problems
High Blood Pressure
Kidney Disease
Liver Disease
Lung Disease
Mental Problems
Seizures
Stroke
Thyroid Problems
Other
Please list any other medical conditions in your family history.
Please print and bring with you on your visit to our office.
