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Internal Medicine MD:
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Name/Ages of people in household
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What is your Occupation?
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Height
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Weight
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What is your Highest Weight?
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What is your Goal Weight (lbs.)
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Prescription Medications
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Dose
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Prescription Medications
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Dose
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Prescription Medications
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Dose
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Prescription Medications
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Dose
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Prescription Medications
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Dose
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Prescription Medications
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Dose
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Prescription Medications
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Dose
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Medications Allergies
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Over the counter medications
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Health History
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Other Medical Conditions
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Please list previous surgeries.
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Were you overweight as a child
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Please list food allergies.
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Family Medical History (parents)
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Do you use tobacco products?
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If yes, what kind and how much?
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Do you drink alcohol?
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If yes, what kind and how much?
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Do you ever skip meals?
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Do you work shift work?
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How often do you dine out?
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Where do you eat your meals?
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Eating Pace
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You feel your appetite is
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After eating you feel
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Reasons to skip meals or overeat
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How do you feel when you eat?
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What diets have you tried?
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Do you exercise?
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What kind of exercise do you do?
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How often do you exercise?
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Other Physical Activities
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How did you hear about us?
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