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Name:
Age:
Sex:
Present Status:
1. Are you in good health at the present time to the best of your knowledge?
Explain a “no” answer:
YesNo
2. Are you under a doctor’s care at the present time?
If yes, for what?
YesNo
3. Are you taking any medications at the present time?
YesNo
Prescription Drugs:
List all
Drug:
Dosage:
Over-the-Counter medications, vitamins, supplements:
List all
YesNo
Product:
Dosage:
4. Any allergies to any medications?
Please list:
YesNo
5. History of High Blood Pressure?
YesNo
6. History of Diabetes?
YesNo
At what age:
7. History of Heart Attack or Chest Pain or other heart condition?
YesNo
8. History of Swelling Feet
YesNo
9. History of Frequent Headaches?
YesNo
Migraines?
YesNo
Medications for Headaches:
10. History of Constipation (difficulty in bowel movements)?
YesNo
11. History of Glaucoma?
YesNo
12. History of Sleep Apnea?
YesNo
13. Gynecologic History:
Pregnancies:
Number:
Dates:
Not Set
Natural Delivery or C-Section (specify):
Menstrual:
Onset:
Duration:
Not Set
Are they regular:
YesNo
Pain associated:
YesNo
Last menstrual period:
Hormone Replacement Therapy:
YesNo
What:
Birth Control Pills:
YesNo
Type:
Last Check Up:
14. Serious Injuries:
YesNo
Specify: (list all)
Date:
15. Any Surgery:
YesNo
Specify: (List all)
Date:
16. Family History:
Father:
Age
Health
Disease
Cause of Death
Overweight?
Mother:
Age
Health
Disease
Cause of Death
Overweight?
Brothers:
Age
Health
Disease
Cause of Death
Overweight?
Sisters:
Age
Health
Disease
Cause of Death
Overweight?
Has any blood relative ever had any of the following:
Glaucoma:
YesNo
Who:
Asthma:
YesNo
Who:
Epilepsy:
YesNo
Who:
High Blood Pressure:
YesNo
Who:
Kidney Disease:
YesNo
Who:
Diabetes:
YesNo
Who:
Psychiatric Disorder:
YesNo
Who:
Heart Disease/Stroke:
YesNo
Who:
Past Medical History:
(check all that apply)
- Polio- Measles- Tonsillitis- Jaundice- Mumps- Pleurisy- Kidneys- Scarlet Fever- Liver Disease- Lung Disease- Whooping Cough- Chicken Pox- Rheumatic Fever- Bleeding Disorder- Nervous Breakdown- Ulcers- Gout- Thyroid Disease- Anemia- Heart Valve Disorder- Heart Disease- Tuberculosis- Gallbladder Disorder- Psychiatric Illness- Drug Abuse- Eating Disorder- Alcohol Abuse- Pneumonia- Malaria- Typhoid Fever- Cholera- Cancer- Blood Transfusion- Arthritis- Osteoporosis
Other:
Nutrition Evaluation:
1. Present Weight:
Height (no shoes):
Desired Weight:
2. In what time frame would you like to be at your desired weight?
3. Birth Weight:
Weight at 20 years of age:
Weight one year ago:
4. What is the main reason for your decision to lose weight?
5. When did you begin gaining excess weight? (Give reasons, if known):
6. What has been your maximum lifetime weight (non-pregnant) and when?
7. Previous diets you have followed:
Give dates and results of your weight loss:
8. Is your spouse, fiancee or partner overweight?
YesNo
9. By how much is he or she overweight?
10. How often do you eat out?
11. What restaurants do you frequent?
12. How often do you eat “fast foods?”
13. Who plans meals?
Cooks?
Shops?
14. Do you use a shopping list?
YesNo
15. What time of day and on what day do you usually shop for groceries?
16. Food allergies:
17. Food dislikes:
18. Food(s) you crave:
19. Any specific time of the day or month do you crave food?
20. Do you drink coffee or tea?
YesNo
How much daily?
21. Do you drink cola drinks?
YesNo
How much daily?
22. Do you drink alcohol?
YesNo
What?
How much daily?
Weekly?
23. Do you use a sugar substitute?
Butter?
Margarine?
24. Do you awaken hungry during the night?
YesNo
What do you do?
25. What are your worst food habits?
26. Snack Habits:
What?
How much?
When?
28. Do you thing you are currently undergoing a stressful situation or an emotional upset? Explain:
29. Smoking Habits: (answer only one)
You have never smoked cigarettes, cigars or a pipe.
You quit smokingyears ago and have not smoked since.
You have quit smoking cigarettes at least one year ago and now smoke cigars or a pipe without inhaling smoke.
You smoke 20 cigarettes per day (1 pack).
You smoke 30 cigarettes per day (1-1/2 packs).
You smoke 40 cigarettes per day (2 packs).
30. Typical Breakfast
Typical Lunch
Typical Dinner
Time eaten:
Time eaten:
Time eaten:
Where:
Where:
Where:
With whom:
With whom:
With whom:
31. Describe your usual energy level:
32. Activity Level: (answer only one)
Inactive - no regular physical activity with a sit-down job.Light activity - no organized physical activity during leisure time.Moderate activity - occasionally involved in activities such as weekend golf, tennis, jogging, swimming or cycling.Heavy activity - consistent lifting, stair climbing, heavy construction, etc., or regular participation in jogging, swimming, cycling or active sports at least three times per week.Vigorous activity - participation in extensive physical exercise for at least 60 minutes per session 4 times per week.
33. Behavior style: (answer only one)
You are always calm and easygoing.You are usually calm and easygoing.You are sometimes calm with frequent impatience.You are seldom calm and persistently driving for advancement.You are never calm and have overwhelming ambition.You are hard-driving and can never relax.
34. Please describe your general health goals and improvements you wish to make:
This information will assist us in assessing your particular problem areas and establishing your medical management. Thank you for your time and patience in completing this form.
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