New Patient Questionnaire Template (Page 2 of 4) in pdf



New Patient Questionnaire

Page 2 of 4

EATING BEHAVIORS:

I eat when I am:

 Stressed/anxious

 Feeling angry

 Feeling depressed

 Feeling bored

 Feeling good or celebrating

 I eat out a lot

 I tend to nibble

 I regularly have second helpings

 I rarely eat fruits and vegetables

 I rarely steam, bake, broil, or grill

 I regularly eat desserts, especially sweets

ALCOHOL AND TOBACCO:

Do you smoke?

 No

 Yes If yes, how much? __________________________________________________________________________

Did you smoke in the past?

 No

 Yes If yes, start date: ____________ Stop Date: _________________________

Do you drink alcohol?

 No

 Yes If yes, how often? ______________________________________________________________________

Do you drink caffeine?

 No

 Yes If yes, how often? _____________________________________________________________________

Do you use recreational drugs?

 No

 Yes If yes, what types and how often? __________________________________________________

EXERCISE:

List the exercise programs you have tried: ___________________________________________________________________________________

_____________________________________________________________________________________________________________________

Do you exercise regularly?

 No

 Yes If yes, what kind and how often? ______________________________________________________

_____________________________________________________________________________________________________________________

What prevents you from exercising? ________________________________________________________________________________________

How many flights of stairs do you climb? _____________________________________________________________________________________

MEDICAL HISTORY: Check all that apply.

Heart Disease:

 High Blood Pressure

 Chest Pain/Heart Attack

 Heart Failure

 Irregular Heart Rhythm

 Bleed Easily

 DVT (blood clots)

 Bruise Easily

Pulmonary:

 Shortness of Breath

 COPD

 Asthma

 Pulmonary Hypertension

 Hypoventilation

 Pulmonary Emboli

 Wheezing

 Chronic Cough

Peripheral Vascular Disease:

 Stroke or TIA

 Lower Extremity Edema

 Neuropathy

 Calf Tenderness

 Cramps in legs while walking

 Cramps in legs at night

Sleep:

 Sleep Apnea

Year Diagnosed: __________

 Daytime Drowsiness

 Snoring

 Insomnia

 Waking up short of breath at night

Gastrointestinal:

 Milk Intolerance

 Persistent Nausea/Vomiting

 Hypoglycemia

 GERD

 Diarrhea/Constipation

 Reflux Disease / Heartburn

 Liver Disease

 Gallbladder Disease or Stones

 Stomach Ulcers

 Colonoscopy

Year: __________

Endocrine:

 Diabetes

 GOUT

 High Cholesterol/Triglycerides

 Thyroid Disease

 Heat/Cold Intolerance

 Unusual or excess hair growth or loss

Musculoskeletal:

 Rheumatoid Arthritis

 Osteoporosis

 Ankle Pain

 Osteoarthritis

 Neck/Back Pain

 Hip/Knee Pain

 General Muscle Pain/Fibromyalgia

Neuro/Psychiatric:

 Depression

 PTSD

 Psychiatric Hospitalization

 Dizziness

 Seizures/Convulsions

 Anxiety

 Psychiatric Treatment

 Fainting

 Numbing/Tingling

 Treatment by: _______________________________________________

Reproductive:

 Not Applicable

 Polycystic Ovarian Syndrome

 Menstrual Irregularity

 Pap Smear

Date: __________

 Mammogram

Date: __________

003700-20120213

BARIATRIC

Intranet: Clinical Hub\Bariatrics\Form

New Patient Questionnaire Template Page 2

Related Articles

Related forms

Related Categories