Integrated Medical Weight Loss

First and Last Name * Address * Date of Birth * Home Phone Number Mobile/Cell Phone Number * Email Address Would you like to be added to our Email List? What is your preferred method of communication: * What is preferred method for receiving documents (i.e. provider notes, lab orders, etc...) Employer Name / Occupation Check One Primary Care Provider (name & address) Emergency Contact (Name. Relationship & Phone #) How did you hear about us? Primary Insurance Plan & ID Number Secondary Insurance Plan & ID Number Preferred PHARMACY Name & Address

Medical History

List All Medical Problems List all Medications currently taking: (include vitamins & over the counter Meds) Allergies to Medications: List Mental/Emotional Problems (incl Medication & Provider) Surgeries (incl Surgeon & Year) Number of Pregnancies / # of Miscarriages / Complications: Date of Last Physical Exam: Last Bloodwork: Last EKG: Have you had a Stress Test? What were results: Have you had a Sleep Study? (If yes, incl results): Do You Smoke? If Yes, # of packs/per day / Age Started / Age Stopped Servings of Alcohol per day: Other Drug Use: Hours of Sleep per night? Do you think you have a problem with sleep? What do you do for Exercise? School / Work History: Hobbies: Who Lives with You? Are you Safe there?

Family History

For each member of family, please list: Age, Medical Problem, If deceased (age & cause of death).

Mother Father Siblings Children Spouse

Weight History

Current Weight Current Height When did your Weight Problem Begin? Highest Weight (not pregnant): Past Weight Loss Attempts List Weight Gains: Are there food/eating triggers in your environment? Do you feel like you "know what to do, but just can't do it" when it comes to eating well? Do you feel you have a problem with: Do you believe food or eating can be addictive? Do you think food is addictive for you? What is your most important motivation to lose weight? How do you think we can help you lose weight?

Review of Systems

Please check all where the answer is YES

Constitutional Systems Eyes Ears/Nose/Mouth/ Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin, breast) Neurological Psychiatric Endocrine Hemotologic/ Lumphatic Allergies (skin or other adverse reaction) Other Allergies (food, drugs, environment) Have you had the following NOT already mentioned above in your medical problem list::