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: ________________
PAST MEDICAL HISTORY: (circle all that apply)
Fax: ______________________
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
Cough Wheezing Asthma/COPD Shortness of Breath Blood Clot in Lung Sleep Apnea/CPAP
Other:
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
Musculoskeletal:
Arthritis – where?
Neck Pain Knee Pain
Psychiatric:
Mood Disorders:
Sleep Issues:
Eating Disorders:
Addiction:
Other:
Tremor
Stomach Pain Bloating Reflux
Gall Bladder Disease Other:
Genitourinary:
Frequent Bladder Infections
Other:
Endocrine:
Low Thyroid
Multiple Sclerosis
Kidney Infection
Diarrhea
Kidney Stones
Fibromyalgia
Foot Pain Other:
Overactive Thyroid
Other:
Constipation
Kidney Failure
Osteoporosis
Adrenal Problems
Pre-Diabetic
Gout
Pancreatitis
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 Pills Other: ____________
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 your parents, 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 Nutrisystem hCG
Fasting/Very Low Calorie Lipotropics/Adipex Prescription Diet Pills (please list all):
Other:
How much did you lose?
Did you gain that weight back? Yes
If so, how much did you gain back?
How long did it take to gain back?
OTC Diet Pills
No
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:
Stress Eating Emotional Eating
Grazing Carbohydrate Craving
No
Night Time Eating
Mouth Hunger
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
Confusion/Memory 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: