CONFIDENTIAL PATIENT INFORMATION


Name:

Address:

City / State / Zip:

Phone:

Date of Birth

MEDICAL HISTORY QUESTIONAIRE
Directions: Please answer all of the following questions to the best of your ability. The answers to these questions will be used to determine which supplemental medications will be used with your program.

PHYSICAL

  • Age: Sex: Weight:
  • Height: Blood Pressure: /

GENERAL

  1. Allergies to medications:
  2. Habits: Smoke? YES NOAlcohol? YES NO
  3. List all current medications:
  4. Chronic illnesses?
  5. Have you ever been treated for:

    Depression YES NO
    Bi-Polar Depression YES NO
    Anxiety YES NO
    Panic attacks YES NO
    Hiatal hernia YES NO
    Ulcer YES NO
    Headaches YES NO
    Hypertension YES NO
    Low blood pressure YES NO
    Sleep Apnea YES NO
    Heart murmer YES NO

  6. Other, please explain:

WEIGHT HISTORY

  1. At what weight do you feel most comfortable? lbs.
  2. My weight problem beganyears ago. Age:
  3. My lowest weight, as an adult waslbs. Age:
  4. My highest weight was or is lbs. Age:
  5. I have tried to lose weight times in the last 5 years.
  6. I have tried: Jennie CraigNutra Systems First Place
    Weight Watchers Form-U-3
    Other:
  7. Number of times each week that I exercise is:
    4-5 2-3 1 or less not at all

COMPULSIVE EATING QUESTIONS

Do you eat when you are not hungry? YES NO
Do you spend a lot of time thinking about food? YES NO
Do you average 2 or more binges per week? YES NO
Do you feel out of control during these binges? YES NO
Do you look forward, with pleasure and anticipation, to the moments when you can eat alone? YES NO
Do you eat sensibly when you are with others and make up for it when you are alone? YES NO
Do you crave to eat at certain times of the day or night, other than meal times? YES NO
Do you eat when you are worried or troubled? YES NO
Do you feel guilty after overeating? YES NO
Are you overly concerned with your appearance, weight, or shape? YES NO
Do you induce vomiting when you overeat? YES NO
Do you regularly use diuretics or laxatives to prevent weight gain? YES NO
Do you resent it when others tell to use will power or self-control with your overeating? YES NO
Does your obsession with food make you and others unhappy or uncomfortable? YES NO
Does your weight effect the way that you live your life? YES NO

I HAVE READ AND ANSWERED ALL OF THE ABOVE QUESTIONS, TO THE BEST OF MY KNOWLEDGE. IF I EXPERIENCE ANY DIFFICULTY WITH ANY PART OF MY PROGRAM, I WILL DISCONTINUE THE PROGRAM AND CONTACT THE CLINIC IMMEDIATELY.

___________________________________________________
(SIGNED)

___________________________________________________
(DATE)

PLEASE PRINT THIS COMPLETED QUESTIONNAIRE AND SEND WITH YOUR ORDER FORM BY FAX OR MAIL.