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New Patient Check-In
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Follow-Up/Existing Patient Check-in
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Primary care physician
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How did you hear about us?
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Age
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Reason for Visit
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Medications:
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Allergies
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Medical History
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Medical History
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High Blood Pressure
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Eating Disorder
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Epilepsy
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Kidney Disease
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Heart Attack/Chest Pain/other heart conditions?
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Bleeding Disorder
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Glaucoma
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Heart Valve Disorder
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Bi-Pollar Illness
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Thyroid Disease
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Hyperlipidemia/High Cholesterol
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Liver Disease
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Anemia
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Heart Disease
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Drug Abuse
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Alchohol Abuse
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Any other condition not listed
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Do you have any family or medical history important to your care not mentioned?
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Has your mom, dad, brother/sister, ever had a heart attack or stroke?
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Nutrition & Lifestyle
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When did you begin gaining excess weight?
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What is your main reason for losing weight?
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What is your desired weight?
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How often per week do you eat out?
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How many times a day do you eat a meal?
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Food allergies:
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What foods do you crave?
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Have you tried any diets previously?
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What is your activity level?
• • •
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Medications Prescribed at Hotty Body
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List if there are any changes to all current medications:
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Have you experienced any negative signs or symptoms since taking appetite suppressants?
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If so, Please explain:
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Type Name for Patient Signature
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