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REASON FOR VISIT TODAY
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Weight Loss/Maintenance
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Weight Loss Program
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Medical Weight Loss Program
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Weight Loss
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Surgery Pre-op and Post-op
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General and Weight Loss surgery
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Lap Band Maintenance
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Lap Band Concerns
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Weight Loss Review
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Weight Loss Review form
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Current clothing size
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clothing fit
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Last breakfast
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Last Lunch
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Last Dinner
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Liquid calories/drinks
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Snacks in last 24 hours
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Have portion sizes increased or decreased since your last visit?
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Nutrition Obstacles
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Obstacles other
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Medication use
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Medication use comments
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Medication side effects
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Medication Side Effect comment
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Exercise
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Exercise Duration average per session
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Exercise Frequency per week average
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Exercise obstacles
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Exercise comments
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Hormone Treatment
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Hormone Treatment
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HORMONE TREATMENT WOMEN
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Women Hormone Reasons
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Low Estrogen
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Hot flashes
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Hot Flashes Day time_________# per week
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Hot Flashes Night time_________# per week
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Night sweats
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Night Sweats _________# per week
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Night sweats - areas
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Vaginal dryness
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Intercourse symptoms
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Incontinence
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Estrogen Dominant
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Irregular periods
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Menstrual Frequency
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Menstrual Flow
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Menstrual Pain/cramps
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Uterine fibroids
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Water retention
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Tender breasts
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Fibrocystic breasts
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Increased forgetfulness
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Foggy thinking
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Tearful
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Depressed
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Mood swings
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Adrenal Function
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Stress
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Morning fatigue
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Afternoon Fatigue
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Evening fatigue
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Difficulty sleeping
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Decreased stamina
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Anxious
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Irritable
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Nervous
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Ringing in ears
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Fibromyalgia
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Allergies
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Headaches
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Sugar cravings
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Dizzy spells
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Thyroid Function
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Cold body temperature
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Goiter
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Hoarseness
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Hair dry or brittle
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Nails breaking or brittle
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Constipation
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Slow pulse rate
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Rapid Heartbeat/Heart palpations
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Metabolic Syndrome/High Androgen
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Infertility problems
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Acne
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Increased facial hair/body hair
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Scalp hair loss
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Weight gain-hips
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Weight gain-waist
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High cholesterol
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Elevated triglycerides
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Low Androgen/Other
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Decreased libido
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Decreased muscle size
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Thinning skin
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Rapid aging
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Aches and pains
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Bone loss
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Comments
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HORMONE TREATMENT MEN
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Men Hormone onset and severity
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Estrogen Dominant
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Prostate problems
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Decreased urine flow
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Increased urinary urge
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Metabolic Syndrome/Low Androgens
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Weight gain - chest/hips
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Weight gain - waist
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Decreased libido
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Decreased erection
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Ringing in ears
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High cholesterol
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High cholesterol
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Elevated triglycerides
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Hot flashes
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Night sweats
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Decreased mental sharpness
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Increased forgetfulness
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Decreased muscle size
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Decreased flexibility
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Sore muscles
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Increased joint pain
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Neck or back pain
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Bone loss
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Rapid aging
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Thinning skin
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Decreased stamina
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Burned out feeling
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Infertility problems
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Stress
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Morning fatigue
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Evening fatigue
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Difficulty sleeping
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Apathy
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Depressed
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Foggy thinking
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Anxious
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Adrenal
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Irritable
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Nervous
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Headaches
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Sugar cravings
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Dizzy spells
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Allergies
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Thyroid/Other
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Cold body temperature
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Goiter
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Hoarseness
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Hair dry or brittle
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Constipation
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Slow pulse rate
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Rapid heartbeat/Heart palpations
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Thyroid Related symptom comments
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WELLNESS
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Primary Care Wellness Visit
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Wellness
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Primary Care Illness
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Illness
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Stem Cell/Biologics - Medical
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Biologic
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Laboratory/Phlebotomy
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Lab/Phlebotomy
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CBD Consultation or Follow up
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CBD
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Medical Aesthetics including biologics
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mediical aesthetics
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Aesthetics Interests & History
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What Procedures Interest You?
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What would you like to achieve from your treatments
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Conditions you have or have had in the past
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What areas of concern do you have regarding your skin? (check all that apply)
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Your Skin Care
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Have you had a facial before?
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Most recent facial treatment
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Have you had a body spa treatment before?
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Which describes you when exposed to sun for 30 minutes with no SPF
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Do you have any skin conditions or concerns pertaining to your face or body?
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Skin Conditions, specify
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Have you ever had chemical peels, laser, or microdermabrasion?
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Peel type
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Do you use any of the following and when last used:
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What general skin care products are you using?
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Acne Medication?
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Brand of Acne Medication
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Have you recently used any self-tanning lotions, creams, or treatments?
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Have you used any of these hair removal methods in the last 4 weeks
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Ever had an allergic reaction to the following?
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Allergic reactions to dermatologics describe:
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What SPF do you use on your face? How often/When?
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What SPF do you use on your body? How often/When?
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In the last 2 weeks, have you had and tanning bed or sun exposure?
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Tanning in the last 2 weeks; did you burn?
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Injections in the last 2 weeks
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Female Patients Only
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Are you taking oral contraceptives?
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Any recent changes to or from your contraceptive treatment?
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Are you pregnant or trying to become pregnant?
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Lactating?
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Any menopause problems?
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Are you undergoing any hormone replacement therapy?
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Male Patients Only
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What is your current shaving system?
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Do you experience irritation from shaving?
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Ingrown hairs?
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Permissions for Technician
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Intravenous or Intramuscular Nutrition
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IV or IM Nutrition
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REVIEW OF SYSTEMS
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No new symptoms or problems
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I have new symptoms or problems to report
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Pain Assessment
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Location of pain or discomfort
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Where
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location additional
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Type of pain or discomfort
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Quality
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quality additional
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Severity of pain or discomfort
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Level of discomfort
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severity additional
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Timing of pain or discomfort
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How often
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timing additional
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When did this problem start?
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Onset and Duration
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onset additional
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How did this start?
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Context
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Is this getting better or worse
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Course
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What makes this worse?
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aggravating factors
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Aggravating additional
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What makes this better?
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Alleviating Factors
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Alleviating additional
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General [-]
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General
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General Comments
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Skin [-]
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Skin
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Skin Comments
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Head, Eyes, Ears, Nose, Throat
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HEENT
• • •
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HEENT Comments
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Neck [-]
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Neck
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Neck Comments
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Breasts [-]
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Breasts
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Breasts Comments
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Cardiovascular [-]
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Cardiovascular
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CV Comments
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Respiratory [-]
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Respiratory
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Resp Comments
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GI [-]
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GI
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GI Comments
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Urinary [-]
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Urinary
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Urinary Comments
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Genital (Male) [-]
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Genital (Male)
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Genital (Male) Comments
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Genital (Female)
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Genital (Female)
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Genital (Female) Comments
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Periph. Vasc. [-]
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Periph. Vasc.
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Periph. Vasc. Comments
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MSK [-]
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MSK
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MSK Comments
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Nervous System[-]
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Neurological
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Neuro Comments
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Endocrine [-]
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Endocrine
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Endo Comments
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Mental Health [-]
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Psychiatric
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Psychiatric Comments
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LAST COMPLETE PHYSICAL AND PCP
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Date of last complete physical exam
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Primary Care Provider/Family Doctor
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PCP Contact Information
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PERSONAL MEDICAL AND SURGICAL HISTORY
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No new or updated history
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New Medical/Surgical History
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Medical History
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Past Medical History adolescent to adult
• • •
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Past Medical History Freewrite
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Surgeries
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Past Surgical History
• • •
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Past Surgical History comments
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Childhood Injuries
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Childhood illnesses
• • •
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Childhood Illness Comments
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Immunizations
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Immunizations
• • •
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Immunization Comments
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FAMILY MEDICAL HISTORY
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No new family history to report or update
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New family history to report or update
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Father
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Father
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Father Comments
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Mother
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Mother's
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Mother Comments
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Siblings
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Sibling(s)'
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Sibling Comments
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Grandparents
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Grandparent's
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Grandparent Comments
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Children
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Children(s)'
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Children comments
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SOCIAL HISTORY
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No updates to social history
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New social history
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Marital Status
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Environmental risks
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Living Arrangements
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Comments
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Sexual Hx
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Comments
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Occupation
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Caffeine
• • •
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Comments
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Alcohol Use
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Other Substances
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Comment
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