Weight Loss Program Patient Information Form Page 2
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4Please list any vitamins/herbs/homeopathies/other you are taking ____________________________________________
__________________________________________________________________________________________________
Are you pregnant? ⃝ Yes
⃝ No
If yes, what month? _________________________________________
What are your current health concerns? _________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Do you have, or have you had, any of the following ( Please check all that apply) ?
⃝ pneumonia
⃝ mumps
⃝ influenza
⃝ rheumatic fever
⃝ smallpox
⃝ pleurisy
⃝ polio
⃝ chickenpox
⃝ thyroid disease
⃝ diabetes
⃝ epilepsy
⃝ cancer
⃝ depression
⃝ whooping cough
⃝ anemia
⃝ eczema
⃝ measles
⃝ arthritis
⃝ heart disease
⃝ rashes
⃝ colitis
⃝ stroke
⃝ allergies ________________________________________________
If you ever been diagnosed with another disease or condition, please describe __________________________________
__________________________________________________________________________________________________
Do you drink
⃝ coffee
⃝ tea
⃝ alcohol
Do you use
⃝ cigarettes
⃝ recreational drugs ⃝ artificial sweeteners
⃝ sugar
Have you ever suffered from (please check all that apply)
⃝ neck pain
⃝ difficulty breathing
⃝ discolored urine
⃝ low back pain
⃝ stuffy nose
⃝ gas/bloating after meals
⃝ headache
⃝ fainting
⃝ heartburn
⃝ migraines
⃝ weigh loss
⃝ irritable bowel
⃝ arm pain/tingling
⃝ poor appetite
⃝ black or bloody stools
⃝ shoulder pain
⃝ excessive appetite
⃝ constipation
⃝ hand pain/tingling
⃝ nervousness
⃝ hemorrhoids
⃝ leg pain/tingling
⃝ confusion
⃝ liver problems
⃝ jaw pain
⃝ depression
⃝ paralysis
⃝ chest pain
⃝ dental problem
⃝ numbness
⃝ lung problems
⃝ excessive thirst
⃝ fatigue
⃝ heart problems
⃝ frequent nausea
⃝ dizziness
⃝ abnormal blood pressure
⃝ prostate problem
⃝ loss of sleep
⃝ irregular heartbeat
⃝ breast pain/lump
⃝ difficulty hearing
⃝ ankle swelling
⃝ cramps
⃝ ear pain
⃝ cold extremities
⃝ painful urination
⃝ other__________________
⃝ blurred vision
⃝ bladder trouble
__________________________
⃝ vision problems
⃝ excessive urination
__________________________
The above is accurate to the best of my knowledge.
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_________________________
(signature)
(date)
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