Language
English (US)
Español
Medical History Form (weight Loss Clinic)
Complete the form and we will reach out to you to get you started on the path to optimal health. NO MORE EXCUSES!
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
Do you have any medication allergies?
*
Yes
No
Not Sure
If yes, Please List
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:
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?
*
Yes
No
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 1-5, how would you describe your body?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
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 ?
Yes
No
Is there anything that will prevent you from participating in a fitness program?
Yes
No
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 HEALOR, to contact me to schedule a weight loss consultation.
Signature
Clear
Today's Date
*
-
Month
-
Day
Year
Date Picker Icon
Submit
Print Form
Should be Empty: