Medical History (Page 3 of 3) in pdf

Medical History Page 3

What are your worst food habits?

When you are under a stressful situation at work or family related, do you tend to eat more?

Yes No

Explain:

Are you currently experiencing a stressful situation or emotional upset?

Yes

Explain:

Are you a smoker or have you ever been? Yes No (If you answered yes to either question, please list

number of cigarettes per day, how long, and if no longer smoking when you stopped:__________

______________________________________________________________________________

Typical Breakfast

Typical Lunch

Typical Dinner

________________________

Describe your energy level:

Activity Level: (answer only one)

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 jogging, swimming, cycling or active sports at least three times per week.

Vigorous Activity- participation in extensive physical exercises for at least 60 minutes per

session.

Please describe any regular exercise in which you engage:_____________________________

____________________________________________________________________________

Dr. Baker will review this information with you which will assist him in developing a safe and

effective weight loss program individualized for you.

Medical History Page 3