Last Name*
First Name*
SSN (Social Security Number)*
Gender* Man Woman
Address*
PHONES:
Mobile (Phone) No.*
Home (Phone) No.
Email*
Profession
Name of Employer
How did you find out about the doctor?*
EMERGENCY CONTACT INFORMATION:
Full Name
Family Relationship
Phone No.
WEIGHT HISTORY
Weight (in kg)*
Height (in cm)*
BODY MASS INDEX (BMI)
BODY TYPE IN:
Childhood Normal with a little more weight with lots of extra kilos overweight obese
Adolescence Normal with a little more weight with lots of extra kilos overweight obese
Adulthood Normal with a little more weight with lots of extra kilos overweight obese
Recent years Normal with a little more weight with lots of extra kilos overweight obese
Comments
Is your partner, your children or others at home overweight? Yes No
Is your partner, your children or others positive about your weight loss goal? Yes No
What changes are you making or thinking about making in your diet and lifestyle habits?
WEIGHT LOSS ATTEMPTS
Diet/nutrition and lifestyle changes: At what age, type and duration of diet or lifestyle changes, how much weight you lost and how long you maintained the weight loss.
Prescription weight loss drugs: Which drug did you take and for how long? Were there any side effects? How much weight did you lose and how long did you maintain the weight loss?
Invasive and surgical weight loss: Which weight loss surgery did you perform? Were there any problems or complications? How much weight did you lose and how long did you maintain the weight loss?
Why do most weight loss attempts fail?
PEDIATRIC MEDICAL HISTORY
Have you gone through the typical (common) childhood illnesses?
Have you suffered from any other serious or unusual illnesses such as hepatitis, rheumatic fever, Type 1 diabetes, kidney diseases, cancer, etc. during childhood?
Have you ever experienced excessive bleeding after an injury or tooth extraction? Yes No
Have you ever needed a blood transfusion? Yes No
Other diseases (please, describe here in detail)
FOR WOMEN
Did you have normal (vaginal) births or C-sections?
How many pregnancies have you had in total?
Do you have a history of recurrent miscarriages, and if so, has it been investigated?
Did you have any complications during pregnancy?
How long ago was your last normal menstrual period?
FOR MEN
Do you have problems with your prostate?
Do you have trouble urinating (such as difficulty initiating urination, urinary dribbling, feeling of incomplete bladder emptying, etc)?
How many times do you get up at night to urinate?
PAST SURGICAL HISTORY
* Yes No
Describe the type of surgery, date, hospital and outcome – complications
1.
2.
3.
4.
MEDICATIONS
* Yes No
Please, note all medications that you are currently using and their dosages. Do not neglect to mention the medications that are not taken daily but only when symptoms are present.
1.
2.
3.
4.
5.
6.
7.
8.
Are you taking any medications to reduce the blood clot? Yes No
ALLERGIES
* Yes No
1.
2.
3.
4.
Is your father alive? Yes No
Serious diseases
Is your mother alive? Yes No
Serious diseases
Brothers and Sisters:
Are your brothers and sisters alive? Yes No
Serious diseases
SOCIAL HISTORY
Do you smoke? Yes No
Did you smoke in the past? Yes No
When did you stop smoking?
How many packs of cigarettes did you smoke a day?
How many years did you smoke in total?
Do you drink alcohol? Yes No
Which is your favorite drink?
How often do you drink?
How many glasses do you drink at a time?
What kind of job have you done for most of your life?
Have you worked in an environment with exposure to risk factors such as chemicals, asbestos, smoke, etc.?
GASTROINTESTINAL
Have you lost weight recently without dieting or changing your dietary habits? Yes No
Do you have pain or difficulty swallowing? Yes No
Do you have loss of appetite or an aversion to certain foods? Yes No
Have you noticed any changes in your bowel habits? Yes No
Have you noticed black stools or blood in your stools? Yes No
Do you have chest pain, heartburn or other reflux symptoms? Yes No
CARDIOVASCULAR
Do you have chest pain when you get tired or walk up stairs? Yes No
Do you sleep with pillows under your neck due to shortness of breath (dyspnea)? Yes No
Do you wake up at night with shortness of breath (dyspnea)? Yes No
RESPIRATORY
Do you have difficulty breathing when you get tired or you walk up stairs? Yes No
Can you walk up 2 flights of stairs without having shortness of breath (dyspnea) or pain? Yes No
Have you noticed any changes in your voice? Yes No
Do you have a chronic cough or phlegm? Yes No
Have you ever coughed up blood? Yes No
URINARY
Do you have felt a burning or stinging sensation or do you have pain or blood when you urinate? Yes No
Do you have a history of Urinary Tract Infections (UTIs)? Yes No
Have you had renal colic? Yes No
Do you have a history of pyelonephritis or other kidney (renal) disease? Yes No
NEUROLOGIC
Have you ever had epilepsy or seizures? Yes No
Have you ever had severe headaches? Yes No
Have you ever had a sudden loss of vision or hearing? Yes No
Have you ever had a loss of movement or feeing (numbness) in your limbs? Yes No
MENTAL HEALTH
Have you ever had depression, anxiety, or other emotions that had an impact on your health? Yes No
Have you ever been under the supervision of a psychologist? Yes No
Are you taking any medication for depression? Yes No
Have you ever had problems with alcohol or other drug use? Yes No
Have you used marijuana, cocaine, or other substances in the last year? Yes No
OTHER HISTORY DETAILS & COMMENS
If there is anything else you would like to add or mention, please fill in below
