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PRESENT MEDICAL HISTORY
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Are you under a doctor's care at the present time?
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If yes, for what?
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Are you currently in a pain management program or on disability?
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Do you have a family/primary care physician (PCP) in the Las Vegas area?
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If Yes, physician's name:
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Are you taking any prescribed medications at the present time?
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If Yes, tap here to enter medications
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Medication
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Dosage:
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Medication
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Dosage:
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Medication
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Dosage:
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Medication
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Dosage:
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Are you pregnant? (Females Only)
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Are you currently on hormone replacement therapy? (includes Birth Control)
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If yes, select current therapy(ies)
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Are you currently taking any vitamin or health supplements?
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Please select, if Yes.
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If "Other" selected:
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Do you hve any allergies or adverse reactions to medications or substances?
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If yes, please click here to indicate allergies
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Medication/Substance:
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Reaction
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Medication/Substance:
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Reaction
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Medication/Substance:
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Reaction
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Do you smoke?
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Do you drink alcohol?
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PAST MEDICAL HISTORY
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Allergies
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Other:
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Cardiac Issues
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Other:
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Circulation Issues
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Other:
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Diabetes-Related Issues
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Other:
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Digestive Issues
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Other:
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Eye Issues
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Other:
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Kidney Issues
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Other:
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Lung Issues
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Other:
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Neurological Issues
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Other:
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Psychological Issues
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Other:
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Past Surgical Procedures?
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If yes, please click here to add surgeries
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Surgical Procedure:
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Date
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Surgical Procedure:
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Date
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Surgical Procedure:
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Date
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Surgical Procedure:
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Date
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Has any blood relative ever been diagnosed with any of the following medical conditions?
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Diabetes
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If yes, Who?
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Glaucoma?
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If yes, Who?
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Heart Disease/Stroke?
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If yes, Who?
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High Blood Pressure?
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If yes, Who?
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Kidney Disease?
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If yes, Who?
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Obesity?
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If yes, Who?
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Psychiatric Disorder?
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If yes, Who?
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Thyroid Problems?
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If yes, Who?
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DIET HISTORY
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What is the primary reason for your decision to lose weight?
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When did your weight problem start?
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Have you ever used Prescription Diet Pills?
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List them here:
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Have you ever used Natural Supplements?
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List them here:
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Have you ever used Food Plans?
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List them here:
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Food/Drinks dislikes:
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Foods/Drinks you crave:
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What time of day or night are you the hungriest?
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Do you tend to eat more due to stress or when experiencing an emotional upset?
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Describe your typical energy level over the past few months (choose the statement that best applies)
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How many hours of television do you watch each day?
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Have you ever considered bariatric surgery? (stomach stapling, gastric bypass, gastric band)
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How often do you eat out?
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How much do you spend a week on food?
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PLEASE LIST YOUR DAILY FOOD INTAKE: (Please be as specific as possible, including #of sodas, etc.)
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Breakfast
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Mid-morning Snack
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Lunch
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Mid-afternoon snack
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Dinner
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Late Night Snack
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OTHER HEALTH & WELNESS CONCERNS
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Please check any concerns, procedures or products that may be of interest to you
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