Patient History Questionnaire
The information that is requested in this questionnaire is very important. To give you the best care, and to obtain your insurance approval, we must have complete answers. Please be thorough. Blue or black ink only , please.
Name:
Age: Sex: Occupation: (If retired, what did you do?)
Actual Body Weight Your Measurement Nurse Consult
Measurement Preop Measurement
Height
Ideal Body Weight
Excess Body Weight
Target Weight
What is your frame
size? □ Small □ Medium □ Large
Bust:
Weight:
Hips:
Weight History
Please estimate as closely as possible for all that apply:
Birth Weight lbs. oz.
Life Event Age Weight
Beginning of High School
High School Graduation
Marriage
Lowest Weight in the Past 5 yrs.
Highest Weight in Past 5 yrs.
In your own words, please describe what you hope to accomplish and how you believe your life will change by losing weight?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Past Medical History
Please identify which of the following childhood illnesses you have experienced.
□ Measles □ Mumps □ Chickenpox □ Obesity □ Rheumatic Fever □ Heart Murmur □ Asthma □ Tonsillectomy
Female Patients: No. of pregnancies: ____________ Age of first period: _________ No. of live births: ____________ Date of last period: _________ Miscarriages / Abortions: _______ Obstetric complications: _________________________________________
Do you presently use any of the following:
Birth Control Pills □ Yes □ No List Type: ________________
Estrogens □ Yes □ No List Type: ________________ Other contraceptive method: _____________________________________
Serious Illnesses
Have you had any of the following: □ Hepatitis □ Blood Transfusion □ AIDS / HIV Exposure □ Colitis □ Kidney Disease □ Bleeding Abnormality □ Thyroid Problems: _____________________________________________ Please list below all serious illnesses and hospitalizations you have experienced in adulthood. Major Illnesses Date Treatment __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Major Surgeries Date __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies
Are you allergic to any medications □ Yes □ No If yes, please list medication and reaction: Medication Reaction
Are you allergic to:
Surgical Tape □ Yes □ No Latex □ Yes □ No Iodine □ Yes □ No Any other allergies: _____________________________________________________________________________________
_______________________________________________________________________
Medications
Please list below all medications you are currently taken (including over the counter medications) If not enough space to list please use a separate sheet of paper.
Medication Dose (mg) / Frequency (how often) / and Reason
Do you smoke or use tobacco? □ Yes □ No How often? ____________________
Are you willing to quit? □ Yes □ No Do you use alcohol? □ Yes □ No How often? ____________________
Family History
Family Members Living Age If deceased, age Illness / Cause of Death
Mother
Father
Maternal Grandmother
Maternal Grandfather
Fraternal Grandmother
Fraternal Grandfather
Sibling
Sibling
Please indicate if you have a family history of:
□ Obesity □ Lung Disease, Asthma/Emphysema □ Colon Cancer □ Diabetes □ Kidney Disease □ High Cholesterol □ High Blood Pressure □ Bleeding tendency or Blood Disorder
□ Heart Disease □ Breast Cancer
System Review
Please circle all symptoms you currently experience or have experienced in the past. Feel free to add any additional problems or information.
➢ HEAD, EYE, EAR, NOSE & THROAT: stuffy nose – runny nose – hay fever – sinus trouble – ear ache – headache – blurry vision – double vision – haloes around lights – loss of night vision – buzzing in ears – ringing in ears – discharge from ears – loss of hearing – dizziness – vertigo – loss of balance – sore throat – lump in throat – trouble swallowing – pain with swallowing – hoarseness.
➢ RESPIRATORY: cough – wheeze – shortness of breath at night – use of two pillows – blood in sputum – out of breath with exertion – wake up at night short of breath – wake up at night coughing or choking – asthma – emphysema – bronchitis.
➢ CARDIOVASCULAR: palpations – pounding heart – skipping heartbeat – pains in chest – pains in neck – pains in arms – squeezing of chest – heart attack – heart murmur – abnormal EKG – irregular heartbeat – high blood pressure – pain in legs – cold feet – blue toes – blue fingers – loss of pulse/
➢ GASTROINTESTINAL: heartburn – nausea – vomiting – belching fluid in throat – burning in throat – food sticking in chest – pains in stomach – burning in stomach – acid stomach – diarrhea – constipation – pain with bowel movement – blood in stools – hemorrhoids – fissures – cramps – gassiness – irritable colon – colitis.
➢ GENITOURINARY: pain with urination – trouble starting urine – trouble stopping urine – small urine stream – blood in urine – kidney stones – bladder stones – kidney failure – nephritis – urinary tract infections – frequent urination – getting up at night to urinate – leakage of urine when coughing or sneezing.
➢ Men: discharge from penis – loss of erection – painful erection.
➢ Females: vaginal discharge – vaginal bleeding – pain with intercourse – irregular periods.
➢ ENDOCRINE (GLANDULAR): hypothyroid – hyperthyroid – goiter – Grave’s disease – thyroid nodules – diabetes – adrenal gland tumor – frequent flushing – frequent heavy sweating.
➢ MUSCULOSKELETAL: pain in joints – swelling of joints – redness of skin over joints – warm joints – fluid in joints – arthritis – broken bones – sprains – low back pain – hip pain – knee pain – ankle pain – foot pain – flat feet – slipped disk – herniated disk – sciatica.
➢ NEUROLOGICAL: dizziness – vertigo – falling to the side – falling at night – numbness – tingling – pins and needles sensation – weakness of any muscles – twitching of muscles – weakness of grip – shakiness – tremors – fainting – convulsions – fit – loss of consciousness.
➢ PSYCHOLOGICAL: nervousness – anxiety – depression – thoughts of suicide – suicide attempts – hospitalization for emotional problems – psychiatric treatment – psychological counseling.
List of Medications
Medication Dose (mg)/ Frequency (how often)/ and Reason
Dietary History
Approximate age when you first seriously dieted? _____________________________________
List the diets and diet programs that you have tried:
Programs Yes No Dates Duration MD Supervised? Max. Wt. Loss
Jenny Craig
NutriSystems
Weight Watchers
Optifast
Medi Fast
Fen/Phen/Redux
Meridia
Lindora
T.O.P.S
O.A
Acupuncture
Metabolife
Atkins Diet
Pritikin Diet
List any physician supervised and documented weight loss attempts: ______________________________________________________________________________
______________________________________________________________________________
List any other diets and/or weight loss methods you’ve tried: ______________________________________________________________________________
______________________________________________________________________________
For Female Patients only: Pregnancy # Year Weight at start Weight at delivery
Food Preferences Please indicate which foods would most likely make you go off the diet. Rank each selection from 1 = like very much to 4 = don’t care
____ soda/ soft drink ____ French fries ____ chips/snacks ____ chocolate ____ steaks/ chops ____ candy ____ potatoes ____ pasta ____ cookies ____ pizza ____ cakes/ pies ____ salad dressing
Weight Related Illnesses Have you had, or do you have, any of the following illnesses or symptoms?
1) Heart Disease □ Yes □ No If yes, year diagnosed? ________________
Do you have, or have you had? □ Angina □ M.I. (myocardial infarction) □ CABG (coronary artery bypass graft) □ Abnormal EKG □ Stress test to rule out cardiac problems □ Palpations
2) High Cholesterol □ Yes □ No High Triglycerides □ Yes □ No If yes, year diagnosed: ________________ List Medications: _____________________________________________
3) High Blood Pressure □ Yes □ No If yes, year diagnosed: ________________ List medications: _____________________________________________
4) Diabetes □ Yes □ No If yes, year diagnosed: ________________
□ Gestational? □ Neuropathy? □ Controlled with:
● Diet ● Oral Medication List medication and mg: ______________________ ● Insulin List medication and doses: ____________________
Last fasting blood sugar: ___________________
5) Asthma □ Yes □ No If yes, year diagnosed: ________________ Number of ER visits in the last 2 yrs. _____________ Number of hospitalizations in the last 2 yrs. ___________
Any steroids in the last 2 yrs. □ Yes □ No 6) Shortness of Breath □ Yes □ No
If yes, you can walk _____________ blocks If yes, you can climb ______________ flight of stairs
7) Trouble Sleeping □ Yes □ No □ Morning headache? □ Daytime drowsiness? □ Restless sleep? □ Snoring? □ Awakenings at night? □ Observed apnea?
8) Sleep Apnea Syndrome □ Yes □ No If yes, year diagnosed: ___________ Last sleep study: ________________ Do you use CPAP? ______________
9) Heartburn/ esophagitis/ hiatal hernia □ Yes □ No If yes, year diagnosed: ___________
Have you had an Upper GI series? □ Yes □ No Have you had an Endoscopy? □ Yes □ No List medication: ______________________________________________
10) Belching up acid or sour fluid □ Yes □ No 11) Coughing or choking at night □ Yes □ No 12)Gallbladder Disease □ Yes □ No
If yes, year diagnosed? ___________
13) Leakage of urine with laughing/ coughing/ sneezing □ Yes □ No If yes, do you wear pads frequently? __________
14) Low back strain/ pain/ sciatica □ Yes □ No If yes, are seen by a chiropractor? ____________ Orthopedic Surgeon? ___________ Family Doctor? ___________ List medication: ______________________________________________
15) Pain in hips/ knees/ ankles/ feet □ Yes □ No If yes, are seen by a chiropractor? ____________ Orthopedic Surgeon? ___________ Family Doctor? ___________
16)Weight related injuries and traumas __________________________________________
17)Venous stasis disease □ Yes □ No □ Edema □ Scaly and thick skin □ Leg ulcers □ Varicose Veins 18)Gout □ Yes □ No
If yes, gouty arthritis? ___________ List medications: _____________________________________________
19) (Females Only) Bra Size? _____________
Skin depressions from bra straps □ Yes □ No Do you have shoulder pain? □ Yes □ No
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