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REASON FOR VISIT
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Reason For Visit
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Other Reason for Visit not listed:
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HEALTH HISTORY
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Name & Address of Primary Care Provider/Referral:
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Last Physical Exam
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Most Recent Lab work
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Last EKG
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Last Eye Exam
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Health History
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Other Medical Conditions
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FAMILY HISTORY
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Family Medical History
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Other Family Hx:
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SURGERIES & HOSPITALIZATIONS
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Previous surgeries & Date
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Other Hospitalizations (Reason/Dx) & Year
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Do you have any surgical devices in your body (i.e. screws, pins, plates, etc)?
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If yes, where are they located?
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ALLERGIES
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General Allergies
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Medication Allergies
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Food/Environmental Allergies.
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Prescribed Medications, Over-the-Counter Drugs, Dietary Supplements (inc. vitamins, inhalers)
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Medication Name
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Strength & Frequency
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Medication Name
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Strength & Frequency
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Medication Name
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Strength & Frequency
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Medication Name
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Strength & Frequency
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Prescribed Medications, Over-the-Counter Drugs, Dietary Supplements (inc. vitamins, inhalers)
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BEHAVIOR STYLE
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High Stress Level
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How would you describe yourself
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HEALTH HABITS & PERSONAL SAFETY
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Exercise
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Select one of the following:
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Do you exercise?
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What kind of exercise do you do?
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How often do you exercise?
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Other Physical Activities
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Nutrition
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Rank your Junk Food Intake
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Rank your Salt Intake
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Rank your Fat Intake
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Caffeine
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Rank your caffeine intake
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What types of Caffeine do you drink?
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How many Cups/cans per day?
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Alcohol
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Do you drink alcohol?
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If yes, what kind and how much?
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How many drinks per week?
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Tobacco
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Do you use tobacco products?
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Kind of Tobacco
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Packs Per Day
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How Many Years?
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If you previously used tobacco when did you quit?
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Drugs
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Do you Currently use recreational or street drugs?
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Have you ever taken street drugs with a needle?
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Sex
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Are you sexually active?
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If yes, are you trying for pregnancy?
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If your not trying for pregnancy what contraceptive methods are you using?
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Gynecologic History
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Last GYN Visit?
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How old were you at Onset of Menstruation?
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Date of Last Menstrual Period:
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How often do you get your period (days)?
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Are they regular?
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Heavy Periods, irregularity, spotting, pain, or discharge?
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Are you currently pregnant?
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Birth Control:
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Number of Live Births:
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Pregnancies #
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WEIGHTLOSS PATIENTS ONLY
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Are you dieting ?
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If yes, are you on a physician prescribed medical diet ?
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What diets have you tried?
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How many meals do you eat in an average day?
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Do you ever skip meals?
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Reasons to skip meals or overeat
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How often do you dine out?
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Where do you eat your meals?
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Eating Pace
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You feel your appetite is
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How do you feel when you eat?
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After eating you feel
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Why do you want to lose weight?
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How Much weight would you like to lose?
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How often do you think about losing weight?
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Is this the heaviest you've ever been? If No what was your highest Weight
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What is your Highest Weight?
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When were you last at your Goal Weight (lbs.)
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Were you overweight as a child
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What diets have you tried?
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Other weight loss methods not listed that you have ? What did you like or dislike about each?
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I snack 2 or More times a day
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I rarely Plan Meals
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I skip 1 or More Meals a day
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Reasons to skip meals or overeat
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How often do you dine out?
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Favorite/ Most Frequent Resturant's you Dine at?
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Where do you eat your meals?
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You feel your appetite is
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Eating Pace
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How do you feel when you eat?
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After eating you feel
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Do you exercise?
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How often do you exercise?
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What kind of exercise do you do?
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Other Physical Activities
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Has a Physician Recommended that you lose weight ?
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On a Scale of 1-10 (10 being the highest), how important is it for you to lose weight?
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Are you ready to commit to losing weight?
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Past Medical History (Check all that apply to you)
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