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Medical History Form
 
 

NAME______________________________AGE_________SEX:  M    F

FAMILY PHYSICIAN_________________________________________

  • Are you in good health at the present time to the best of your knowledge?   Y    N
  • Are you under a doctor's care at the present time?                                      Y    N 
  • If yes, for what____________________________________________
  • Are you taking any medication at the present time?                                      Y    N
  • What:___________________________Dosage__________________           
  • What:___________________________Dosage__________________               
  • What:___________________________Dosage__________________             
  • Allergic to any medications?                                                                        Y    N
  • What:___________________________________________________
  • History of high blood pressure?                                                                    Y   N
  • History of Diabetes?                                                                                    Y   N
  • At what age?_____________________________________________
  • History of heart attack or chest pain?                                                           Y   N
  • History of swelling feet?                                                                               Y   N
  • History of frequent headaches?                                                                    Y   N
  • Migraines?  Y___N___Medications for headaches:____________________
  • History of constipation (difficulty in bowel movement)?                                 Y   N
  • History of glaucoma?                                                                                   Y   N
  • Gynecologic history:
    Pregnancies:                          Y__N__  Number:____                              Dates:_________________________ 
    Natural deliveryY__N__

     C-SectionY__N__

    		  
    Menstrual Onset______  Duration________  Regular  Y___N___
    Pain associated:Y__N__  Last menstrual period________  
    Hormone replcement:Y__N__    
    What type:    
    Birth Control Pills: Y__N__    
    Type__________________    
    Last Checkup:    
  • Serious Injuries: (Specify)
  • Any Surgeries: (Specify with date

 

 

  • Family History:
               AGE 

    HEALTH            

    DISEASE      

    CAUSE OF DEATH        

    		OVERWEIGHT 
    FATHER          
    MOTHER          

    BROTHERS

     

    		          

    SISTERS

     

    		          
  • Has any blood relative ever had any of the following:
    Glaucoma              Y   N  WHO:                                                                    
    Asthma Y   N WHO:
    Epilepsy  Y   N WHO: 
    High Blood Pressure  Y  N WHO:
    Kidney Disease  Y   N WHO: 
    Diabetes  Y  N WHO: 
    Tuberculosis  Y   N  WHO:
    Psychiatric Disorder  Y  N WHO: 
    Heart disease/stroke  Y  N WHO: 
  • PAST PERSONAL MEDICAL HISTORY: (Check all that apply)
    Polio  Liver Disease   Tyroid Disease  Alcohol Abuse
    Measles  Lung Disease  Anemia Pneumonia
    Tonsillitis Whopping Cough  Heart Valve Disorder  Malaria
    Jaundice Chicken Pox  Heart Disease Typhoid Fever
    Mumps  Rheumatic Fever  Tuberculosis  Cholera
    Pleurisy  Bleeding Disorder  Gallbladder Disorder  Cancer
    Kidneys  Nervous breakdown  Psychiatric Illness  Blood Transfusion
    Scarlet Fever Ulcers Drug Abuse  Arthritis
    Liver Disease  Gout  Eating Disorder  Osteoporosis
  • OTHER:_______________________________________________________

NUTRITIONAL EVALUATION:

  • Present weight:_______Height (no shoes)________Desired weight___________
  • In what time frame would you like to be at your desired weight_______________
  • Birth Weight________Weight at age 20_______Weight 1 year ago___________
  • What is the main reason for your decision to lose weight?___________________
  • When did you begin gaining excess weight? (Give reasons, if known)
  • What has been your maximum lifetime weight (non-pregnant) and when:
  • Previous diets you have followed:  Give dates and results of weight loss
  • Is your spouse, fiancee or partner overweight?          Y     N  
  • By how much is he or she overweight?_________________________________
  • How often do you eat out?__________________________________________
  • What resturants do you frequent?
  • How often do you eat "fast foods"?___________________________________
  • Who plans meals?______________________________
  • Cooks_______________Shops__________________
  • Do you use a shopping list?    Y       N
  • What time of the day and what day do you shop for groceries?
  • Food Allergies (list):
  • Food dislikes (list):
  • Foods you crave: (list)
  • Any specific time of the day or month that you crave food?__________________
  • Do you drink cofee or tea?  Y    N        How much daily?___________________
  • Do you drink soft drinks?    Y    N        How much daily?___________________
  • Do you drink alcohol?         Y    N        How much?_______________________
  • Do you use a sugar substitute?   Y   N
  • Do you awaken hungry during the night?   Y   N                                                   
  • What do you eat?_____________________________
  • Have you ever found evidence of night time eating without your knowledge? Y  N
  • What are your worst food habits:
  • Snack Habits:    What?____________________________________________
  • When____________________________How Much_____________________
  • When you are under a stressful situation at work or with family, do you tend to reach for food?  Explain____________________________________________
  • Do you think you are currently undergoing a stressful situation or a emotional upset?  Explain___________________________________________________
  • Smoking habits: (Check only one)
         You have never smoked cigarettes, cigars or a pipe 
      You quit smoking____years ago and have not smoked since 
      You have quite smoking cigarettes at least 1 year ago and now smoke cigars or a pipe without inhaling smoke 
      You smoke 20 cigarettes per day (1 pack)
      You smoke 30 cigarettes per day (1 and 1/2 packs) 
      You smoke 40 cigarettes per day (2 packs) 
  • Daily eating habits:
    Typical breakfast                 Typical Lunch                     Typical Dinner           
         
         
         
    Time eaten: Time eaten: Time eaten
    Where: Where: Where:
    With Whom: With Whom:  With Whom:
  • Describe your usual energy level:
  • Activity Level: (Check only one)
        Inactive-not regular physicial activity with a sit-down job
      Light activity-no organized physical activity during leisure time
      Moderate activity-occasionally involved in activities such as weekend golf, tennis, jogging, swimming or cycling
      Heavy activity-consistent lifting, stair climbing, heavy construction, etc....
      Vigorous activity-participation in extensive physical exercises for at least 60 minutes per session 4 times per week.
  • Behavior style (Check only one)
          You are always calm and easy going
      You are usually calm and easy giving
      You are sometimes calm with frequent impatience
      You are seldom calm and persistently driving for advancement
      You are hard-driving and can never relax
  • Please describe your general health goals and improvements you want to make:
  • What kind of dietary approach do you feel is best for you? (Circle One)  FEEL FREE TO LEAVE THIS BLANK, WE WILL GO OVER THIS: 
  • ALL FOOD                                                                                                     
  • ALL FOOD WITH NUTRITIONAL SUPPLEMENTS                                   
  • TOTAL MEAL REPLACEMENT
  • Do you feel you will need medication for appetite suppression?
  • Do you want Vitamin B-12 shots?  (These are not given routinely, but many patients request them)                Y     N

THIS INFORMATION WILL ASSIST US IN ASSESSING YOUR PARTICULAR PROBLEM AREAS AND ESTABLISHING YOUR MEDICAL MANAGEMENT.  THANK YOU FOR YOUR TIME AND PATIENCE IN COMPLETING THIS FORM.



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