Medical History Form

Medical History Form ( weight Loss Clinic)
Full Name *

First Name Last Name
Date Of Birth

- Month - Day Year
Date
Phone Number *

- Area Code Phone Number
Email
example@example.com

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Do you have any medication allergies? *

Yes No Not Sure
If yes, Please List
Severity
Onset
Reaction
Do you have any Food allergies? *

Yes No Not Sure
If Yes, Please List
Severity
Onset
Reaction
Do you have any Environmental allergies (pollen,latex etc)? *

Yes No Not Sure
If Yes, Please List
Severity
Onset
Reaction
Are you currently taking any medication, including Herbs, Supplements etc? *

Yes No
If so, please list:
Have you had Surgery? *

Yes No
If so, please list:
Gender identity

Male Female Transgender Male/Trans Man/Female-to-Male Transgender Female/Trans Woman/Male-to-Female Genderqueer, neither exclusively Male nor Female Additional gender category or other (please specify) Patient declines to specify
Sexual orientation

Straight or heterosexual Lesbian, gay, or homosexual Bisexual Something else, please describe Don't know Patient declines to specify
Past medical history (Check the conditions that apply to you ): *

Diabetes High blood pressure Heart Disease Cancer Stroke Seizures Lung Disease (Asthma, COPD, etc.) HIV Sleep Anpea GastroesophagealReflux (GERD, heartburn) Arthritis / Joint Pain Back Pain Depression Infertility / PolycysticOvaries Irregular MenstrualCycles Stress UrinaryIncontinence (leakage) Thyroid disease Liver Disease Kidney Disease Venous Insufficiency Gallstones Blood Clots in Leg /Lung (DVT/PE) Previous bariatric surgery Hysterectomy other

Family medical history *

	Diabetes	High blood pressure	Heart Disease	Lung disease (Asthma, COPD)	Cancer	Stroke	Seizures	None	Unknown
Father
Mother
Brother
Sister
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother

Preventive care history

	Past year	2 Years	5+ years	Never
Routine Physical
Eye Exam
Colonoscopy
Bone Density Scan
Flu Shot
Pneumonia Vaccine
Prostate exam(M)
Mammogram(F)
Pap smear (F)

How often do you consume Tobacco? *

Daily Weekly Monthly Occasionally Never
How often do you consume alcohol? *

Daily Weekly Monthly Occasionally Never
Do you use or do you have history of using illegal drugs? *
Obesity History
What is the main reason who decided to lose weight?
How long have you been obese?
What is your current weight?
How does your weight limit you?
What do you think is the reason for your weight gain?
What do you see as your two biggest barriers to weight loss?
Is you spouse, partner overweight?

Yes No
How often you dine out? What Restaurants do you frequent? What types of foods you eat there?
What foods you avoid?
What foods do you crave?
Do you awaken hungry during the night

Yes No
What are you worse food habits?
what are you snack habits?
Rate you body from 1-10, how would you describe your body?
If you could change one thing about your body, what would it be?
Describe your typical breakfast? ( what time, where, with whom?
Describe Your typical Lunch?
Describe Your Dinner?
How often do you Exercise?

Daily Weekly Monthly Occasionally Never
Has a physician ever told you NOT to participate in a fitness or exercise program ?
Is there anything that will prevent you from participating in a fitness program?
Weight Management History
What have you tried so far?

Low calorie diet Low fat diet Atkins diet Optifast®/ Medifast® Phen-Fen Diet shots (B12, etc.) Doctor-supervised diet Registered Dietician (RD) Exercise program Nutrisystem® Weight Watchers® Jenny Craig® LA Weight Loss other
Sleep Assessment
How many hours of sleep do you get per night?

6 or less 8 or less 10 or less
Do you feel rested when you wake up in the morning?

yes No
Has anyone ever told you that you stop breathing while you sleep?

yes No
Check the symptoms that you have experienced in the PAST 6 WEEKS *

Fever/Chills Unexplained change in weight Fatigue/Malaise/Generalized weakness Headaches/Migraines Dizziness Sinus Pain/Pressure/Discharge Excessive snoring Wheezing/Chronic Cough Shortness of breath Chest pain, pressure or tightness Swelling of hands/feet/ankles Nausea/Vomiting Abdominal pain Heartburn Constipation or diarrhea Stiffness/Pain in joints/muscles Joint swelling Bleeding/Easy bruising Excessive urination Excessive thirst/hunger Hot flashes Painful/Bloody urination Difficulty urinating/Night-time urination Urinary incontinence (leakage) Sexual Difficulties/Painful intercourse Rash Anxiety/Panic Attacks Concentration Difficulty Feelings of Guilt Insomnia/Problems with Sleep Loss of energy Thoughts of harming self or others None
How healthy do you feel in general?
I give my express permission to DOKcare Medical, to contact me to schedule a weight loss consultation.
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Today's Date *

- Month - Day Year
By signing and submitting this form, I consent DokCare medical to start my weight loss program Subscription. The subscription continues Monthly unless cancelled by written 30 day notice.

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Medical History Form ( weight Loss Clinic)

Obesity History

Weight Management History

Sleep Assessment