Patient Medical History Form Page 3
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5Past Medical History: (check all that apply)
Polio
Measles
Tonsillitis
Jaundice
Mumps
Pleurisy
Kidneys
Scarlet Fever
Liver Disease
Lung Disease `
Whooping Cough
Chicken Pox
Rheumatic Fever
Bleeding Disorder
Nervous Breakdown
Ulcers
Gout
Thyroid Disease
Anemia
Heart Valve Disorder
Heart Disease
Tuberculosis
Gallbladder Disorder
Psychiatric Illness
Drug Abuse
Eating Disorder
Alcohol Abuse
Pneumonia
Malaria
Typhoid Fever
Cholera
Cancer
Blood Transfusion
Arthritis
Osteoporosis
Other:
Nutrition Evaluation:
1. Present Weight:
Height (no shoes):
Desired Weight:
2. In what time frame would you like to be at your desired weight?
3. Birth Weight:
Weight at 20 years of age:
Weight one year ago:
4. What is the main reason for your decision to lose weight?
5. When did you begin gaining excess weight? (Give reasons, if known):
6. What has been your maximum lifetime weight (non-pregnant) and when?
7. Previous diets you have followed:
Give dates and results of your weight loss:
8. Is your spouse, fiancee or partner overweight?
Yes
No
9. By how much is he or she overweight?
10. How often do you eat out?
11. What restaurants do you frequent?
12. How often do you eat “fast foods?”
13. Who plans meals?
Cooks?
Shops?
14. Do you use a shopping list?
Yes
No
15. What time of day and on what day do you usually shop for groceries?
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Parent category: Medical