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ࡱ>    J/bjbj 8%F F 8tb9 p}n d8888888$J;=8-"nn""89o(o(o("8o("8o(o(47=n#U7F8290b97Fl>$Xl>7l>7!Zp!@o(!4!!!!88'!!!b9""""l>!!!!!!!!!F O:  (If you brought a copy of your Patient History from your surgeons office, complete the first page and any other information it does not provide.) Please provide as much information as you have. Todays Date _____/______/_______ Name__________________________________________ Age______ Date of Birth _____/______/_______ Referred by: _______________________________________________________________________________ Ethnic Background: African-American Asian HispanicAmerican Indian CaucasianOther__________________Education: Less than 12th gradeGED (year) _____________High school ______________Some technical trainingCompleted technical trainingSome college  FORMCHECKBOX  CollegeHighest degree/certificate: ____________________ Field: _____________________________________If you are in school, where and what are you studying? _______________________________________________ Marital Status: Never MarriedSeparatedDivorced, but Not RemarriedMarriedWidowedDivorced and RemarriedLiving with a Significant OtherOther, specify:_______________________________________Children (if not previously given) - Names and ages: _________________________________________ ___________________________________________________________________________________ Home with whom do you live now? _____________________________________________________ ___________________________________________________________________________________ Occupation: __________________________________________Employer ______________________________ Prior jobs (last 10 years): ________________________________________________________________________ PHYSICIANS: Primary Care or Family Doctor: ________________________________________________________________ Address_______________________________________________________________________________________________ Phone________________________________________ Fax____________________________________________________ Surgeon (or surgical clinic): ___________________________________________________________________ Psychiatrist: ________________________________________________________________________________ Other MDs (and specialty): ___________________________________________________________________ ___________________________________________________________________________________________ Weight and Dietary History Your Height__________ Current weight__________ How long have you been at this weight?___________ How old were you when you went on your first diet?______ How much did you weigh at that time?_______ Please write in the number of times you tried each of the following in an attempt to lose weight. (Write in the number of times that you attempted each program and the dates.) Number of AttemptsYear of each attemptAmount lost, length of time before regainMedications: Redux Phen-Fen Meridia Amphetamines Xenical Other, specify:__________________ _________ _________ _________ _________ ________________________ _______________ _______________ _______________ _______________ ______________________________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________Medically Supervised Program Name of Program:  _________ ________________Registered Dietitian or Nutritionist  Non-Prescription: MetabolifeDexatrim/AcutrimLaxativesDiuretics/Water pills Weight Watchers Nutri-Systems Jenny Craig Diet Center TOPS or OA PsychotherapyAcupuncture/HypnosisHealth Club or classesWorking out at home/WalkingOther: MEDICAL HISTORY Use approximate year or age of occurrence Current Medical conditions: Illness/conditionSince:illness/conditionSince: Current Medications: (If not provided elsewhere. Include inhalers and birth control.) NameDose & frequencyNameDose & frequency Vitamins: ___________________________________________________________________________________ Hospitalizations (that did NOT involve surgery): Include childbirths and method of delivery Reason for Hospitalization DateReason for Hospitalization DateSurgeries: Type of Surgery DateType of Surgery DateEATING PATTERN AND DAILY SCHEDULE Fall asleep:___________ Wake up: __________ Leave home: __________ Work hours: _____________ Hours of sleep per night: __________ How well do you sleep? Rate your sleep (circle a number): 1 2 3 4 5 6 7 8 9 10 |________|________|________|________|________|________|________|________|________| Very poorly Still tired in AM Could be better Not bad Usually good Great How many meals do you usually eat each day? ___________ Snacks? ____________________________ What kinds of foods do you tend to eat most of the time? _______________________________________ _____________________________________________________________________________________ Do you eat breakfast (or a meal after you wake up)?  FORMCHECKBOX Yes  FORMCHECKBOX No  FORMCHECKBOX Sometimes If so, what do you eat? ______________________________________________________________ Do you snack during the day?  FORMCHECKBOX  3 or more times  FORMCHECKBOX Twice  FORMCHECKBOX Once  FORMCHECKBOX Occasionally  FORMCHECKBOX  Never What about at night, or toward the end of your day?  FORMCHECKBOX Regularly  FORMCHECKBOX Occasionally  FORMCHECKBOX  Never Do you wake up at night to eat?  FORMCHECKBOX Often  FORMCHECKBOX Occasionally  FORMCHECKBOX Rarely  FORMCHECKBOX Never  FORMCHECKBOX I used to Do you ever eat in your sleep?  FORMCHECKBOX Often  FORMCHECKBOX Occasionally  FORMCHECKBOX Rarely  FORMCHECKBOX Never  FORMCHECKBOX I used to Do you tend to graze or nibble throughout the day?  FORMCHECKBOX Often  FORMCHECKBOX Occasionally  FORMCHECKBOX Rarely  FORMCHECKBOX Never  FORMCHECKBOX I used to What are typical snacks? ________________________________________________________________ Do you tend to pay attention to what you eat?  FORMCHECKBOX Always  FORMCHECKBOX Usually  FORMCHECKBOX Occasionally  FORMCHECKBOX  Never Do you ever eat without realizing it?  FORMCHECKBOX Often  FORMCHECKBOX Occasionally  FORMCHECKBOX Rarely  FORMCHECKBOX Never  FORMCHECKBOX I used to Do you ever binge-eat?  FORMCHECKBOX Often  FORMCHECKBOX Occasionally  FORMCHECKBOX Rarely  FORMCHECKBOX Never  FORMCHECKBOX I used to Do you eat for emotional comfort?  FORMCHECKBOX Often  FORMCHECKBOX Occasionally  FORMCHECKBOX Rarely  FORMCHECKBOX Never  FORMCHECKBOX I used to Do you ever eat out of boredom?  FORMCHECKBOX Often  FORMCHECKBOX Occasionally  FORMCHECKBOX Rarely  FORMCHECKBOX Never  FORMCHECKBOX I used to Do you overeat?  FORMCHECKBOX Often  FORMCHECKBOX Occasionally  FORMCHECKBOX Rarely  FORMCHECKBOX Never  FORMCHECKBOX I used to Do you pay attention to the nutritional content of food?  FORMCHECKBOX Always  FORMCHECKBOX Sometimes  FORMCHECKBOX Never Do you read labels?  FORMCHECKBOX Yes  FORMCHECKBOX Occasionally  FORMCHECKBOX  Rarely  FORMCHECKBOX Never How often do you cook or prepare meals at home?  FORMCHECKBOX Daily  FORMCHECKBOX Occasionally  FORMCHECKBOX Rarely/never If so, how many times a day (when home)?  FORMCHECKBOX Once  FORMCHECKBOX Twice  FORMCHECKBOX Three times  FORMCHECKBOX More Are you happy with your eating habits and choices?  FORMCHECKBOX Yes  FORMCHECKBOX No  FORMCHECKBOX Usually If not, why not? _______________________________________________________________________ Are there habits you want to change? ______________________________________________________ Family MEDICAL History Please identify medical problems in your family to the best of your knowledge. FatherMotherSiblingsGrandparentsAunts/UnclesFathers parentsMothers parentsFathers siblingsMothers siblingsWeight: (< 20#) Low Normal Range (20-34#) Overwt (35-79#) Mild-Mod (e" 80#) Sev-Morbid High Blood PressureHigh CholesterolHeart DiseaseStrokeDiabetes MellitusSleep ApneaArthritisCancer, _________Other:Other:Cause and age of death, if deceased:  DepressionBipolar disorderAnxietySuicidePsychiatric Hosp.Schizophrenia Alcohol abuseDrug abuseCD Treatment Do you have children with medical problems? What are they? _________________________________ __________________________________________________________________________________________________________________________________________________________________________     PATIENT HISTORY PAGE  PAGE 5 Stephen M. 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