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Concern: Obesity
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Onset Date
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Severity of Symptoms
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Status of weight loss
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Risk Factors
• • •
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Risk Factors Other
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Associated Conditions
• • •
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Associated Conditions Other
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Aggravated by
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High fat diet
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Lack of exercise
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Medications
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Poor mobility
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Pregnancy
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Recent marriage
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Recent surgery
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Recent trauma or injury
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Smoking cessation
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Snacking
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Aggravated by
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Aggravated By Other Positives
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Aggravated By Other Negatives
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Relieved by
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Diets
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What Diets have you tried?
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Exercise
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What Exercise have you tried?
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Medication
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What medications have you tried?
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Surgery
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What Surgeries have you tried?
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Relieved by
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Relieved By Other Positives
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Relieved By Other Negatives
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Associated Symptoms/Pertinent Negatives
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YES = Positive, NO = Negative
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Associated Symptoms/Pertinent Negatives
• • •
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Abdominal Pain
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Acne
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Amenorrhea
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Anhidrosis
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Anorexia
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Anxiety
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Cold Intolerance
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Constipation
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Depression
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Delayed Development
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Facial plethora
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Fatigue
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Generalized Weakness
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Hair Loss
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Headache
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Hirsutism
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Hoarseness
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Lethargy
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Low self-esteem
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Oligomenorrhea
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Paresthesias
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Striae
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Vision changes
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Other associated symptoms
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Other pertinent negatives
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Relevant Findings
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Computer/television time (hr/week)
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Comments
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