Patient Medical History Form Page 4
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516. Food allergies:
17. Food dislikes:
18. Food(s) you crave:
19. Any specific time of the day or month do you crave food?
20. Do you drink coffee or tea? Yes
No How much daily?
21. Do you drink cola drinks?
Yes
No
How much daily?
22. Do you drink alcohol?
Yes
No
What?
How much daily?
Weekly?
23. Do you use a sugar substitute?
Butter?
Margarine?
24. Do you awaken hungry during the night?
Yes
No
What do you do?
25. What are your worst food habits?
26. Snack Habits:
What?
How much?
When?
27. When you are under a stressful situation at work or family related, do you tend to eat more? Explain:
28. Do you thing you are currently undergoing a stressful situation or an emotional upset? Explain:
29. Smoking Habits: (answer only one)
You have never smoked cigarettes, cigars or a pipe.
You quit smoking
years ago and have not smoked since.
You have quit smoking cigarettes at least one year ago and now smoke cigars or a pipe without
inhaling smoke.
You smoke 20 cigarettes per day (1 pack).
You smoke 30 cigarettes per day (1-1/2 packs).
You smoke 40 cigarettes per day (2 packs).
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