By clicking “SEND” at the end, this information will reach our private secured site where only our medical personnel will have access to them.

Patient’s name …………………………………………………………………………………………….……

                                    Last                                   Middle                              First

Today’s date ………….………… Date of birth ……...….…………Age…..… Sex: M….. F…..

Home phone: …………………….Cellular: ……..…..……………Work: …………………………….

Address: ………………………………………………..…………………………………………………………..

                         Street                             City                                  State                      Zip

 

Marital status:  Single….  Married….  Widower ….   Divorced …. Race: ……….………..

Nearest relative name: ………………………………………………..…………………………………….

Last                      Middle                             First

Relationship: ……………………………………………………. Phone: ………..…………………………

Address: ………………………………………………………………………………………………………….…

                          Street                             City                                 State                       Zip

Are you being currently treated by a physician? No…... Yes…..., please explain

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Primary physician: …………………………………………………… Phone: ……………………………

Occupation: ………………………………How many hours per week do you work: ……….

Present diet: Please write in a paper everything that you eat every day for a full week, paying special attention to snacks and weekends. This is essential to detect problems and implement necessary changes.

How much water do you consume per day? (number of glasses) ……………………….

Caffeine (coffee, tea, cola), number of cups/cans per day ………………………………….

Are you dieting? No…... Yes…...

Do you exercise?  

No exercise  …..

Mild exercise (climb stairs, walk 3 blocks, play golf) …..

Moderate exercise (Vigorous work or recreation sport for 30 minutes, less than 4 times per week)…..

Severe exercise (Vigorous work or recreation sport for at least 30 minutes, 4 or more times per week) …..

How long have you been overweight? ………………….…….

How much weight do you want to lose? ……………………

You want us to focus on: Neck:………  Arms:………. Abdomen:…..….

      Buttocks:…….….  Thighs:……… Chest: ………. Cellulite:……….

Are other members of your family overweight:   No…... Yes…...

Have you ever had or do you have now any of these problems (check mark each one that apply or, if none applies, check here ……):

Alcohol abuse….

AIDS/HIV positive….

Anemia….

Angina….

Arthritis….

Asthma….

Back problems….

Blood disease….

Blood transfusion….

Breathing problem….

Breast lump....

Cancer….

Colitis….

Convulsions/Seizures….

Cough, chronic….

Depression….

Diabetes….

Disability/Handicapped….

Drug abuse….

Ear trouble/Hearing loss….

Eating disorder….

Eye disease….

Gallbladder disease…

Gastrointestinal trouble (constipation, diarrhea, vomit, etc.)….

Gout….

Hay fever….

Head injury

Headaches/ Migraine….

Heart disease (heart failure, murmur, irregular beats, pacemaker, stents)….

Hepatitis B or C/ Jaundice….

Hernia….

High blood pressure….

Infectious diseases (chicken pox, hepatitis, infectious mononucleosis, measles, mumps, poliomyelitis, rubella, scarlet fever, shingles, tuberculosis, urinary tract infection, sexually transmitted disease, etc.)….

Joint disease (arthritis, pain, gout, rheumatism)….

Osteoporosis….

Paralysis….

Pneumonia….

Psychiatric care….

Psychologic counseling….

Radiation therapy….

Sickle cell anemia….

Sinusitis….

Skin problems….

Sleep problems….

Smoking (how long)….

Stroke….

Suicidal thoughts/attempts….

Surgery….

Thyroid disease….

Tumors or growths….

Weight loss, recent….

Other….

Describe answers to above, with dates: ……………………………………………………………….

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List drug allergies: ...............................................................................................................

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List current medications, both prescription and over the counter (indicate drug name, strength and frequency):

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List current nutritional supplements or herbal teas:

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Referred by ………………………………………….……………………………………………………….…..

How did you hear about us ………………………………………………………………………………..

 

Women only 

Are you still having monthly menstruation? No ….  Yes …. Last period: ………………

Period every …… days.

Are you pregnant?     No ….  Yes,  how long?…….……………

Are you trying to get pregnant? No …. Yes ….

Number of children ….

Men only

Erectile disfunction ….

Testicular lump ….

Prostate problem ….

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my health. I clearly understand and agree that all services rendered are charged directly to me and that I am personable responsible for payment.

Signature of patient    (type your name)  .................................................................Date .........

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