Phone

List any medications you are taking Please include dosage and frequency:

List any medications you are allergic to and the reaction you had to them.

List any beliefs or reasons why you would refuse any form of medical treatment.

If necessary at any time during your treatment, are you able to accept blood products?

Are there any conditions that you are being treated for not listed here? If so, please specify:

Mother

Father:

Siblings

Children

Smoking/Tobacco Use:

Previous smoker/tobacco use:

Alcohol:

Non- Prescribed Drug Use/Substance Abuse:

Caffeine

Employment:

Marital Status:

Were you overweight as a childteenager

Which of the following weight loss programs/personal diet plans have you tried in the past?

Diet Program Attempted: Physician Supervised

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Weight Watchers

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Medical Weight Loss Centers

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Jenny Craig

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Slim Fast

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Liquid Protein Fast

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: LA Weight loss

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: New You

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: HMR

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Heart Center Supervised

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: TOPS

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Gym Membership

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Calorie Counting

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Exercise Videos

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Diet Modification

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Weight Loss Medication

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Diet Program Attempted: Hospital Based/Supervised

Most Weight Lost (approx.) in lbs.

Typical Weight Regain (approx.) in lbs.

Duration (if known)

Please list any other weight loss attempts you have tried and the outcome of each

NOTE: Your insurance may require documentation of previous weight loss attempts. Please bring any documentation you may have with you to your appointment.

Weight loss Medication: Dexatrim

Weight lost (appox)

Weight Regained (approx.)

Weight loss Medication: Ali

Weight lost (appox)

Weight Regained (approx.)

Weight loss Medication: Xenecal (Orlistat)

Weight lost (appox)

Weight Regained (approx.)

Weight loss Medication: Meridia

Weight lost (appox)

Weight Regained (approx.)

Weight loss Medication: Redux (Dexfenluramine)

Weight lost (appox)

Weight Regained (approx.)

Weight loss Medication: Fen-Phen (Fenfluramine, Pondimin)

Weight lost (appox)

Weight Regained (approx.)

Weight loss Medication: Phentermine

Weight lost (appox)

Weight Regained (approx.)

Weight loss Medication: Qsymia

Weight lost (appox)

Weight Regained (approx.)

Weight loss Medication: Caffeine Pills (black beauty, noDos, yellow jackets)

Weight lost (appox)

Weight Regained (approx.)

Other Prescription Medication:

Weight lost (appox)

Weight Regained (approx.)

Other OTC Medications

Weight lost (appox)

Weight Regained (approx.)

Please use the following space to address any further health or weight loss issues or concerns that you may have.