<p> Allergy and Weight Loss Center (Concord Weight Loss Clinic) Weight and Nutrition History Name: ______Date of birth: ______Today’s Date: ______Primary Physician: ______How did you hear about our program? ______Maximum lifetime weight:______Desired weight:______Please circle all that apply: How long you have been overweight? Since childhood > 5 years < one year What situation led to your weight gain? Stress, college, divorce, career change, pregnancy, menopause, medications, other______What weight loss methods have you tried before? Diet pills, Weight watchers, Surgery, Other______</p><p>Dietary history: (please list typical meals) Breakfast: ______Lunch:______Dinner:______Snacks:______Night eater?______When is the hungriest time of your day? Morning Afternoon Evening How many times a week do you eat out? ______What type of food? Chinese, Fast foods, Indian, Italian, Mexican, other______How many sodas, diet sodas per day? ______</p><p>Exercise and activity: Inactive (sedentary)_____ Light activity_____ Moderate activity_____ What type of activity do you do now? ______</p><p>Sleep: Do you suffer from sleep disturbance? Explain______</p><p>Current Medications and Dosages:</p><p>Allergies to medications: ______Indicate if you or your family has a history of the following conditions: You Family Member You Family Member Diabetes Sleep Apnea High blood pressure Asthma/COPD High cholesterol Heartburn Stroke Eating disorder Heart Disease Arthritis Thyroid disease Other Cancer Other</p><p>Personal History: Who lives at home besides you?______Highest degree of education______What is your occupation?______Are you: Single____ Married____ Domestic partnership____ Divorced____ Widowed____ Smoking: Currently smoking____ Amount?____ Never smoked____ Quit smoking ____ When?____ Alcohol: Yes /No How many drinks per week? ______Are you sexually active: Yes/No Use birth control? Yes/No Are you trying to conceive? Yes/No Review of systems: (circle all that apply) Constitutional Fever Chills Weight loss Weight gain Appetite change Fatigue Night sweats</p><p>Skin Itch Skin infection Nail infection Dry Stretch marks Acne Rash</p><p>Eyes: Vision change Pain Swelling Redness Discharge Light sensitivity Contact lens</p><p>Ears: Itch Pain Discharge Hearing loss Chronic infections</p><p>Nose/Throat/Neck Itch Congestion Drainage Difficulty/painful swallowing Voice change Pain :</p><p>Heart Chest pain Palpitations Swelling in feet</p><p>Lungs: Cough Wheezing Shortness of breath Coughing up blood Snoring</p><p>GI: Heartburn Nausea/vomiting Diarrhea Constipation Abdominal pain Blood in stool</p><p>GU: Difficulty/pain on urination Blood in urine Excessive urination Leaking urine </p><p>Musculoskeletal: Pain Stiffness Numbness/tingling Swelling</p><p>Endocrine: Heat/cold intolerance Hair loss Unusual thirst Skin pigment change Sweating</p><p>CNS: Seizure Dizziness Weakness Loss of balance Sleep problems Headaches Memory loss</p><p>Men: Erectile dysfunction Loss of sex drive Breast enlargement Testicular pain/swelling</p><p>Women: Hot flashes Vaginal dryness Irregular periods Dark hair growth on face/chest/abdomen</p><p>Weight Loss Resistance Questionnaire</p><p>Do you… Yes No</p><p>Metabolic switch/Insulin Resistance/Carb Sensitivity… Frequently crave sugar? Have mood swings or energy fluctuations that influence your eating? Gain weight in your upper body/mid-section?</p><p>Stress Eating… Have stress-induced cravings for salt, sugar, or fatty foods? Eat carbs after a stressful day?</p><p>Food allergies… Have leaky gut syndrome? Have a history of frequent colic, ear infections, food allergies? Suffer from nasal congestion, sinusitis, asthma, hives, or eczema? Have irritable or irregular bowels? Have muscle aches, joint pains, chronic headaches?</p><p>Night eating syndrome… Have sleep problems (trouble falling or staying asleep, fragmented sleep) Have daytime drowsiness? Snore? Take sleeping pills? Skip breakfast? Eat most of your calories after 5pm? Wake up to eat at night?</p><p>Detoxification problems… Have fibromyalgia or chronic fatigue syndrome? Take NSAIDs (Motrin, Advil, Ibuprofen), Anti-depressants, steroids (prednisone), beta-blockers (Atenolol, Metoprolol), Psychiatric medications?</p><p>For women only… Experience craving and weight gain with PMS? Have weight gain associated with menopause? ------FOR OFFICE USE ONLY:</p><p>Heart Lungs Mallampati Other</p>