<p> Patient Information & History</p><p>Name: ______Today’s Date: ______(Last) (First) (Middle)</p><p>Date of Birth: ______Age: ______Occupation: ______</p><p>Home Address: ______</p><p>City: ______State: ______Zip: ______</p><p>Home Phone: ______Cell Phone: ______Work: ______</p><p>E-Mail Address: ______</p><p>In Case of Emergency Contact: ______Relationship: ______</p><p>Home Phone: ______Cell Phone: ______Work: ______</p><p>Primary Care Physician’s Name: ______Phone: ______</p><p>Address: ______Address City State Zip</p><p>Marital Status (check one): ( ) Married ( ) Divorced ( ) Widow ( ) Single</p><p>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.</p><p>Spouse’s Name: ______Relationship: ______</p><p>Home Phone: ______Cell Phone: ______Work: ______</p><p>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</p><p>Drug allergies: ______</p><p>Medications Currently Taking: ______</p><p>Surgeries, list all and when: ______</p><p>LMP (if applicable): ______</p><p>Other Pertinent Information: ______WEIGHT LOSS QUESTIONAIRRE</p><p>NAME:______DOB:______</p><p>1. HAVE YOU TRIED LOSING WEIGHT ON YOUR OWN WITHOUT MEDICATION? YES/NO</p><p>2. PLEASE LIST ANY DIETS/EXERCISE PLANS YOU HAVE TRIED OR ARE TRYING: ______</p><p>3. WHICH ONES WERE SUCCESSFUL? WHY? ______</p><p>4. PLEASE LIST FACTORS THAT YOU THINK CAUSED YOU TO REGAIN WEIGHT: ______</p><p>5. HAVE YOU TAKEN APPETITE SUPPRESSANTS BEFORE? YES/NO 6. DO YOU EXERCISE REGULARLY? YES/NO </p><p>7. IF NOT, WHAT PROHIBITS YOU FROM EXERCISE?______</p><p>8. WHAT WAS YOUR WEIGHT BEFORE YOUR FIRST PREGNANCY (IF APPLICABLE)? ______</p><p>9. WHAT IS YOUR LIFETIME MAX WEIGHT?______</p><p>10. HOW LONG HAVE YOU BEEN OVERWEIGHT?______</p><p>11. WHAT IS YOUR REALISTIC GOAL WEIGHT?______</p><p>12. WHEN WAS THE LAST TIME YOU WERE AT THAT WEIGHT?______</p><p>13. WHAT IS YOUR MOTIVATION FOR LOSING WEIGHT?______</p><p>14. HAVE YOU EVER SUFFERED FROM AN EATING DISORDER? YES/NO</p><p>15. ACTIVITY LEVEL:</p><p> INACTIVE  LIGHTLY ACTIVE</p><p> MODERATE ACTIVITY</p><p> VIGOROUS ACTIVITY</p>