Medical Questionnaire Form
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3NYU Langone Weight Management Program
MEDICAL QUESTIONNAIRE
Date: _________________________________ DOB: _________________________ Age:______________
Last Name:
First Name: ___________________________________
Medications- Please include ALL medications you take regularly (ALL vitamins, supplements or herbals)
Name of medication
Dose
How often
Start Year
Do you have allergies to medications? Yes / No
If yes, please list; ________________________________________________________________________________________
Do you have an allergy to Latex? Yes / No or
Surgical tape? Yes / No
Do you have allergies to food? Yes / No
If yes, please list; ________________________________________________________________________________________
Prior Surgeries:
Yes
No
Previous coronary angioplasty or stents
Yes
No
Previous heart surgery
Yes
No
Please list other surgeries and indicate dates
Date
Previous obesity surgery
Yes
No
Date:
Hospital:
Type of Surgery:
Surgeon:
Weight at the time of
lbs
Reason for
surgery:
transfer of care:
Medical History
Smoking History
Yes (stopped date:
)
No
Current Smoking:
Yes
No
Alcohol
Yes (how many glasses/wk:
)
No
Diabetes
Yes
No
High Blood Pressure
Yes
No
GERD (Gastroesophageal Reflux Disease)
Yes
No
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Version date: April 10, 2014
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Parent category: Life