Allergy and Weight Loss Center (Concord Weight Loss Clinic)
Weight and Nutrition History
Name: ___________________________
Date of birth: ______________
Today’s Date: _________
Primary Physician: __________________ How did you hear about our program? _________________
Maximum lifetime weight:_____________ Desired weight:_____________
Please circle all that apply:
How long you have been overweight? Since childhood
> 5 years < one year
What situation led to your weight gain? Stress, college, divorce, career change, pregnancy, menopause,
medications, other________________
What weight loss methods have you tried before? Diet pills, Weight watchers, Surgery, Other________
Dietary history: (please list typical meals)
Breakfast: _____________________________________________________
Lunch:________________________________________________________
Dinner:________________________________________________________
Snacks:________________________________________________________
Night eater?____________________________________________________
When is the hungriest time of your day? Morning
Afternoon Evening
How many times a week do you eat out? _______________
What type of food? Chinese, Fast foods, Indian, Italian, Mexican, other______________
How many sodas, diet sodas per day? ____________
Exercise and activity:
Inactive (sedentary)_____
Light activity_____
Moderate activity_____
What type of activity do you do now? _________________________________________
Sleep: Do you suffer from sleep disturbance? Explain____________________________
Current Medications and Dosages:
Allergies to medications: ___________________________
Indicate if you or your family has a history of the following conditions:
You
Family Member
You
Diabetes
Sleep Apnea
High blood pressure
Asthma/COPD
High cholesterol
Heartburn
Stroke
Eating disorder
Heart Disease
Arthritis
Thyroid disease
Other
Cancer
Other
Family Member
Personal History:
Who lives at home besides you?_________________________________
Highest degree of education_____________________ What is your occupation?_________________
Are you: Single____ Married____ Domestic partnership____ Divorced____ Widowed____
Smoking: Currently smoking____ Amount?____ Never smoked____ Quit smoking ____ When?____
Alcohol: Yes /No How many drinks per week? ______
Are you sexually active: Yes/No
Use birth control? Yes/No
Are you trying to conceive? Yes/No
Review of systems: (circle all that apply)
Constitutional
Fever
Chills
Weight loss
Skin
Itch
Eyes:
Vision change Pain Swelling Redness Discharge Light sensitivity Contact lens
Ears:
Itch
Pain
Nose/Throat/Neck:
Itch
Congestion
Heart
Chest pain
Lungs:
Cough
GI:
Heartburn
GU:
Difficulty/pain on urination
Musculoskeletal:
Pain
Endocrine:
Heat/cold intolerance Hair loss Unusual thirst Skin pigment change Sweating
CNS:
Seizure Dizziness Weakness Loss of balance Sleep problems Headaches Memory loss
Men:
Erectile dysfunction
Women:
Hot flashes
Skin infection
Weight gain
Nail infection
Dry
Discharge
Drainage
Palpitations
Wheezing
Stretch marks
Hearing loss
Fatigue
Acne
Night sweats
Rash
Chronic infections
Difficulty/painful swallowing
Voice change
Pain
Swelling in feet
Shortness of breath
Nausea/vomiting Diarrhea
Stiffness
Appetite change
Coughing up blood
Constipation
Blood in urine
Numbness/tingling
Snoring
Abdominal pain Blood in stool
Excessive urination
Leaking urine
Swelling
Loss of sex drive Breast enlargement Testicular pain/swelling
Vaginal dryness
Irregular periods
Dark hair growth on face/chest/abdomen
Weight Loss Resistance Questionnaire
Do you…
Yes
No
Metabolic switch/Insulin Resistance/Carb Sensitivity…
Frequently crave sugar?
Have mood swings or energy fluctuations that influence your eating?
Gain weight in your upper body/mid-section?
Stress Eating…
Have stress-induced cravings for salt, sugar, or fatty foods?
Eat carbs after a stressful day?
Food allergies…
Have leaky gut syndrome?
Have a history of frequent colic, ear infections, food allergies?
Suffer from nasal congestion, sinusitis, asthma, hives, or eczema?
Have irritable or irregular bowels?
Have muscle aches, joint pains, chronic headaches?
Night eating syndrome…
Have sleep problems (trouble falling or staying asleep, fragmented sleep)
Have daytime drowsiness?
Snore?
Take sleeping pills?
Skip breakfast?
Eat most of your calories after 5pm?
Wake up to eat at night?
Detoxification problems…
Have fibromyalgia or chronic fatigue syndrome?
Take NSAIDs (Motrin, Advil, Ibuprofen), Anti-depressants, steroids (prednisone), beta-blockers
(Atenolol, Metoprolol), Psychiatric medications?
For women only…
Experience craving and weight gain with PMS?
Have weight gain associated with menopause?
------------------------------------------------------------------------------------------------------------------------------FOR OFFICE USE ONLY:
Heart
Lungs
Mallampati
Other