Medical Questionnaire Form Page 3
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1
2
3Name:
Date:
Has a physician ever supervised your attempts to lose weight? Yes / No
Doctor/Clinic
City:
Treatment Dates:
Type of Treatment:
_______________________________________________________________________________________________________
Have you tried diet pills? Yes / No
If yes, please list:___________________________________________________________________________
Please check all that you have tried IN THE LAST 10 YEARS.
Year
Weight Loss (lbs)
Year
Weight Loss (lbs)
Atkins
Medifast
Acupuncture
Nutrisystem
Calorie Counting
Nutritionist
Diet Center
Optifast
Fad Diet
Overeaters Anonymous
Herbal Diet
Pritikin
Health Spa
Self Diet
High Protein
Slim Fast
Hypnosis
Start Fresh
Jenny Craig
South Beach
LA Diet
Weight Watchers
Leder
Zone
Low Carbohydrate
Patient Signature:_____________________________________ Date: ______________
MD Reviewed: _______________________________________ Date: ________________
Page 3 of 3
Version date: April 10, 2014
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Parent category: Life