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A person's weight is a function of many personal attributes and the ways they interact with each other. It is therefore pertinent to obtain background information from you in order to determine the best treatment approach. Please complete all 3 pages, and be sure to give details where appropriate.
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Medical History Name:___________________________________ Date:______________ Birth date:_______________ Please answer the following questions: I consider myself to be in good general health. YES NO Have you ever been diagnosed with, or have reason to suspect you may have or have had, any of the following? Please explain any 'yes' answers. Diabetes Thyroid disease (hypothyroid, hyperthyroid, Cancer Heart problems (irregular heartbeat, heart disease) High blood pressure Elevated cholesterol or triglycerides Ever examined by a cardiologist? If so, why? Shortness of breath after walking a short distance or climbing one flight of stairs Kidney stones Gallstones or other gallbladder disease Hypoglycemia Stomach disorders (Heartburn, reflux, gastric ulcers) Intestinal disorders (chronic constipation, diarrhea, enteritis, diverticulitis) Migraines or severe or chronic headaches Fainting spells, dizziness, or vertigo Anemia Arthritis in a weight bearing joint (foot, ankle, knee, hip, back) Glaucoma Gout Seizure disorder or history of convulsions Depression Severe anxiety, panic attacks, or bipolar disorder? Have you ever tried to intentionally hurt yourself? Do you have unpredictable mood swings? Are you currently taking medication, including over the counter or herbal medication? Please list: Do you take vitamin supplements? Please list. Do you have any allergies? Please list. Include drug allergies. YES NO Do you participate in any alternative medicine therapies? Please list. Have you ever had any surgeries? Please List. If female: Are your periods regular? Date of last menstrual period: Are you currently breast feeding? How many pregnancies? Miscarriages? Is there any possibility of you being pregnant? Do you have food cravings before or during your period? Any problems with increased blood pressure or diabetes with pregnancy? Are you using oral or hormonal contraceptives? Any hormonal problems? Do you get regular exercise? Please list types of activities, frequency, and duration. Are you aware of any problems that would be aggravated by exercise? If so, explain: Do you get enough sleep? What is your sleep schedule? Do you have sleep apnea? Do you use tobacco products or have you used them in the past? Are you currently a smoker? If not, how long ago did you quit smoking? How much per day? For how many years? Chewing tobacco? How much caffeine daily? Do you drink alcohol? If so: How much per day / week / month? Wine: Beer: Liquor: Any recreational drugs now or in the past? Any history of chemical dependency? Please explain. Are you aware of any other health concerns that have not been listed above? Please explain. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||