Medical History Form

Name *

First Name

Last Name

Address

City

State

Postal Code

Country

DATE OF BIRTH: *

Pharmacy name and address

Please list all medications, including vitamins, herbal or natural supplements and prescription medications, that you are currently taking. Please add the dosage when possible.

Please list any medication allergies or reactions:

Please check to indicate if you have ever had the following conditions:

If you have any other medical problems or serious injuries that are not listed above , please describe them here:

Do you have menstrual periods?

Regular

Irregular

Does not apply

Please list all surgeries and hospital stays you have had and their approximate date/year:

When was your last physical?

Please specify any family members who are overweight or have major health problems?

Has any blood relative ever had any of the following?

Any additional pertinent family history information

Present Weight:

Height: ( no shoes)

Desired Weight:

In what time frame would you like to be at your desired weight?

Maximum lifetime weight/ when :

Weight at 20 years of age:

Weight one year ago:

What is the main reason for your decision to lose weight?

When did you begin gaining excess weight? (Give reasons, if known):

Previous diets followed in the past. Please give dates and results of your weight loss:

Previous medication (prescribed) or supplements (over the counter) taken for weight loss: Give dates and any side effects:

Do you smoke anything or use any tobacco products?

Yes

No

If yes,

less than a pack daily

a pack daily

more than a pack daily

How often do you have a drink containing alcohol?

Never

Monthly or less

2 to 4 times a month

2 to 3 times a week

4 or more times a week

How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2

3 or 4

5 or 6

more than 6

When you are in a stressful situation at work or family related do you eat more? Please explain?

Do you think you are currently undergoing a stressful situation or an emotional upset? Please explain?

Do you eat out ?

More than 3 meals a week

Less than 3 meals a week

What restaurants do you frequent?

Do you plan your own meals, cook and shop?

Yes

No

Do you use a shopping list?

None

Yes

No

What time of day and on what day do you shop for groceries?

Identify foods that you crave?

Do you drink coffee or tea daily? How much?

Do you drink soft drinks? If yes, how many and how often?

Do you use sugar substitutes?

Do you wake during the night? If so, do you eat?

What is your worst food habit?

What are your snack habits? How much? When?

Do you eat breakfast? If so, what?

What is a typical lunch? Time eaten, with whom, where?

What is a typical dinner? Time eaten, with whom, where?

Describe your activity level *

Inactive- no regular physical activity with a sit down job.

Light activity-no organized physical activity during leisure time.

Moderate activity-occasionally involved in activities such as weekend golf, tennis, jogging, swimming or cycling

Heavy activity-consistent lifting, stair climbing, heavy construction, etc. or regular participation in swimming, cycling or active sports at least three times per week

Vigorous activity- participation in extensive physical exercise for at least 60 minutes per session 4 times per week

Describe your behavior style:(answer only one)

None

Your are always calm and easygoing.

You are usually calm and easygoing.

You are sometimes calm with frequent impatience.

You are seldom clam and persistently driving for advancement.

You are never calm and have overwhelming ambition.

You are hard-driven and can never relax.

Please describe your general health goals and improvements you wish to make?

	Yes	No
Obesity
Asthma
Epilepsy
High Blood Pressure
Kidney Disease
Diabetes
Tuberculosis
Psychiatric Disorder
Heart Disease/ Stroke

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