LAST DIET EVER MEDICAL WEIGHT LOSS CLINIC – MEDICAL HISTORY FORM Current Wt: ____ Ht:_________
Name____________________________________DOB: ___/____/____ Age: _____Spouse/Partner_________________
Address: _______________________________________City: _______________________ ST: _______ ZIP: __________
Phone: _______________ Cell: ________________ Work: _________________ Email: ____________________________
Occupation: _____________________ Marital Status: M S W D Permission to call (circle): Spouse/Partner Doctor
Family Doctor:________________ Phone: ________________
Fax: ______________________
PAST MEDICAL HISTORY: (circle all that apply)
Head and Neck:
Frequent Headaches Migraines Dizziness Fainting Spells Vertigo Confusion Loss of Balance
Loss of Coordination Hearing Loss Speech Problems Memory Loss Difficulty Swallowing Glaucoma
Bleeding Disorders Other:
Lungs:
Smoker
Other:
Cough
Wheezing
Asthma/COPD
Shortness of Breath
Blood Clot in Lung
Sleep Apnea/CPAP
Heart:
Heart Attack – when?_________ Angina Heart Disease Chest Pain High Blood Pressure Arteriosclerosis
Blood Clots – when?_________ where?_________ why? ________________ Clotting Abnormality?
Atrial Fibrillation CHF Stroke Swelling of Ankles Irregular Heartbeat Skipped Beats Palpitations
Vascular Heart Disease Cardiac Surgeries
Other:
Neurological:
Stroke Seizure Disorder
Digestive:
Stomach Ulcer
Diverticulitis
Tremor
Stomach Pain Bloating Reflux
Gall Bladder DiseaseOther:
Genitourinary:
Frequent Bladder Infections
Other:
Musculoskeletal:
Arthritis – where?
Neck Pain Knee Pain
Endocrine:
Low Thyroid
Multiple Sclerosis
Kidney Infection
Psychiatric:
Mood Disorders:
Sleep Issues:
Eating Disorders:
Addiction:
Other:
Diarrhea
Kidney Stones
Fibromyalgia
Foot PainOther:
Overactive Thyroid
Other:
Adrenal Problems
Constipation
Pancreatitis
Kidney Failure
Osteoporosis
Pre-Diabetic
Gout
Liver Disease
Incontinence
Neuropathy
Back Pain
Diabetic Other:
Depression Anxiety Bipolar Disorder Panic Attacks Constant Worry Excessive Stress
Insomnia Poor Quality Sleep Restlessness Insufficient Sleep Excessive Dreaming
Trouble Falling/Staying Asleep Restless Leg Syndrome
Bulimia Anorexia
Drugs Alcohol Food Gambling Sexual Diet Pills Prescription PillsOther:
Females:
Not Applicable
Abnormal Periods __________ Abnormal PAP Smear Infertility Polycystic Ovaries Yeast Infection
Pregnancies - # ________ Menopause Currently Pregnant or Nursing  Yes  No Other:
I agree that I have completed the medical history form to the best of my knowledge. I understand that failure to provide accurate, truthful and
complete information could result in inappropriate treatment.
Patient Signature:
Revised 8/21/12
Date:
Males:
Not Applicable
Erectile Dysfunction Enlarged Prostate
Other:
Weakness
Voice Change
Urinary Problems
Loss of Libido
General:
Cancer/Tumor – where?___________ when?________ Have you been cancer free for the past 5 years? Yes / No
Auto-immune Disease _____________ High Cholesterol Yo-Yo Dieting Fast Metabolizer of Medications
Other:
Surgical History:
Tonsils Gallbladder
Other:
Appendectomy
Joint Replacement
Hysterectomy
Gastric Bypass
Family History: (please circle any conditions yourparents, grandparents, aunts, uncles, brothers or sisters may have)
Diabetes Hypertension Heart Disease Heart Attack Blood Clots Cancer High Cholesterol Stroke
Addiction Allergies to Drugs:
Allergies:
Medications:(please list any and all medications (prescribed and over the counter) and vitamins you are taking)
Other/Notes/Explanations:
Dieting History
Yo-Yo Dieting Calorie Restricted Diet Liquid Diet Weight Watchers NutrisystemhCG OTC Diet Pills
Fasting/Very Low Calorie LipotropicsAdipex Prescription Diet Pills (please list all):
Other:
How much did you lose?
Did you gain that weight back? Yes
No
If so, how much did you gain back?
How long did it take to gain back?
Controlled Substances for Weight Reduction
Have you ever used a controlled substance for weight loss? (i.e. Adipex, Didrex, Bontril, Tenuate, etc.) Yes
Which one(s):
When was the last time you used them?
How much did you lose?
Why did you stop?
Who prescribed it?
Eating Problems
Excessive Appetite Portion Control
Alcohol/Drug Intake Sugar Craving
Other:
No
Stress Eating Emotional Eating Night Time Eating
Mouth Hunger
Grazing Carbohydrate Craving Skipping Meals Low Blood Sugar
Weight Gain Triggers
Pregnancy Surgery Illness Chronic Pain Disability Major Depressive Episode
PubertyMenopause Major Stressor (ex. Divorce, Job Loss, Death in Family, etc.):
Steroid Treatment
CURRENT Symptoms/Conditions
Pregnant Breastfeeding Migraine Headache Tension Headache Dizziness Vertigo Fainting Spells
ConfusionMemory Loss Restless Legs Joint Pain Back Pain Muscle Pain Other Pain:
Swollen Ankles Poor Sleep Not Enough Sleep Disturbed Sleep Shift Work Anxiety Depression Grief
Stress Anger Sadness Worry Irritability Mood Swings Hot Flashes Decreased Libido Dry Skin
Vaginal Dryness Pelvic Pain Hair Falling Out Yeast Infection Abnormal Bleeding Bladder Problems
Breathing Problems Heart Problems Digestive Problems Chest Pain Undiagnosed Signs and Symptoms
Please Describe Detail:
I agree that I have completed the medical history form to the best of my knowledge. I understand that failure to provide accurate, truthful and
complete information could result in inappropriate treatment.
Patient Signature:
Revised 8/21/12
Date: