Female New Patient Package

Patient Information & History

Name: ______Today’s Date: ______(Last) (First) (Middle)

Date of Birth: ______Age: ______Occupation: ______

Home Address: ______

City: ______State: ______Zip: ______

Home Phone: ______Cell Phone: ______Work: ______

E-Mail Address: ______

In Case of Emergency Contact: ______Relationship: ______

Primary Care Physician’s Name: ______Phone: ______

Address: ______Address City State Zip

Marital Status (check one): ( ) Married ( ) Divorced ( ) Widow ( ) Single

In the event we cannot contact you by the mean’s you’ve provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment.

Spouse’s Name: ______Relationship: ______

Habits: ( ) I smoke cigarettes or cigars ______per day. ( ) I drink alcoholic beverages ______per week. ( ) I drink more than 10 alcoholic beverages a week. ( ) I use caffeine ______a day. Medical History

Drug allergies: ______

Medications Currently Taking: ______

Surgeries, list all and when: ______

LMP (if applicable): ______

Other Pertinent Information: ______WEIGHT LOSS QUESTIONAIRRE

NAME:______DOB:______

1. HAVE YOU TRIED LOSING WEIGHT ON YOUR OWN WITHOUT MEDICATION? YES/NO

2. PLEASE LIST ANY DIETS/EXERCISE PLANS YOU HAVE TRIED OR ARE TRYING: ______

3. WHICH ONES WERE SUCCESSFUL? WHY? ______

4. PLEASE LIST FACTORS THAT YOU THINK CAUSED YOU TO REGAIN WEIGHT: ______

5. HAVE YOU TAKEN APPETITE SUPPRESSANTS BEFORE? YES/NO 6. DO YOU EXERCISE REGULARLY? YES/NO

7. IF NOT, WHAT PROHIBITS YOU FROM EXERCISE?______

8. WHAT WAS YOUR WEIGHT BEFORE YOUR FIRST PREGNANCY (IF APPLICABLE)? ______

9. WHAT IS YOUR LIFETIME MAX WEIGHT?______

10. HOW LONG HAVE YOU BEEN OVERWEIGHT?______

11. WHAT IS YOUR REALISTIC GOAL WEIGHT?______

12. WHEN WAS THE LAST TIME YOU WERE AT THAT WEIGHT?______

13. WHAT IS YOUR MOTIVATION FOR LOSING WEIGHT?______

14. HAVE YOU EVER SUFFERED FROM AN EATING DISORDER? YES/NO

15. ACTIVITY LEVEL:

 INACTIVE  LIGHTLY ACTIVE

 MODERATE ACTIVITY

 VIGOROUS ACTIVITY