MEDICAL QUESTIONNAIRE

Name *

Last Name *

Date of Birth *

Gender

Address

Street address
Street line 2
City	State / Province
Zip code	País

E-mail address *

example@example.com

Occupation

Cell Phone *

Status

Age

Insert your body mass index *

Possible date of Surgery *

Please indicate which surgery you are interested in:

How did you find out about us?

Name

Phone numer

Cell

Name of medication, Dose, How often taken, Purpose, When use started.

Example: (A) Metformin, one pill every 8 hours.

Date, Illness, Treatment, Outcome

Surgery, Date, Reason

Have you ever had surgery to aid weight loss? *

Yes No

Do you experience shortness of breath with physical activity?

Yes No

Do you have or have you had asthma?

Yes No

Have you been diagnosed with sleep apnea syndrom?

Yes No

Do you use CPAP?

Do you experience swelling of the ankles?

Yes No

How long?

What do you do to decrease the swelling?

What do you take to relieve the pain?

Thyroid problems?

Yes No

Are you diabetic?

Yes No

How long?

What are you taking for your diabetes?

Do you monitor your blood sugar?

Yes No

How often?

Have you been diagnosed with PCOS?

Yes No

Do you have high blood pressure?

Yes No

How long?

What are you taking for your high blood pressure?

Do you experience chest pain?

Yes No

How long?

Do you have any history of heart disease?

Yes No

Explain:

Have you had a heart attack?

Yes No

Have you been diagnosed with fatty liver, cirrhosis, Hepatitis or any liver disease?

Yes No

Details:

Have you been diagnosed with Rheumatoid Arthritis?

Yes No

Are you taking or have you taken nonsteroidal anti-inflammatory drugs (NSAIDs) for joint pain?

Yes No

Have you been diagnosed for Lupus?

Yes No

Have you been diagnosed as HIV positive?

Yes No

Have you been diagnosed with diverticulitis?

Yes No

Do you have any history of ulcers?

Yes No

Have you been diagnosed with Crohn’s disease or Ulcerative Colitis?

Yes No

Do you have indigestion or heart burn?

Yes No

If so, for how long?

What foods or drinks cause digestive problems for you?

Food/drink – Result of eating/drinking

Do you ever have any type of pain in the abdomen?

Yes No

Pain details (sharp, dull, hot, cold, aching, crushing, etc.)

Have you ever been treated for an eating disorder?

Yes No

Are you generally happy with your life other than your weight?

Yes No

Do you have a history of depression?

Yes No

Have you used tobacco products in the past?

Yes No

Do you use tobacco products now?

Yes No

How many times daily?

How long have you used tobacco products?

Do you ever drink alcohol?

Yes No

If yes, what beverages?

How many drinks per day?

Do you use caffeine (Coffee, cola, chocolate, No-Doz, Aqua Ban)?

Yes No

If yes, in what form?

How much per day?

DO YOU HAVE ANY OF THE FOLLOWING?

Swelling:Locations: Ankles, Knees, Hips, Back, Others.

Pain: Locations:

Ankles Knees Hips Back

Stiffness: Locations:

Ankles Knees Hips Back

Popping/ Crackling: Locations:

Ankles Knees Hips Back

How long have you been overweight?

Have you tried diet pills?

Yes No

What have you done to try to lose weight?

What kind of exercise program have you tried?

Please list any additional information you believe would assist in your health planning:

*

I understand that full disclosure is necessary to my medical safety, I have filled out this medical history to the best of my knowledge, and I have answered these questions with complete honesty to insure my health and safety.

Please Calculate Your Body Mass Index

BMI calculator

PATIENT INFORMATION

PLEASE PROVIDE EMERGENCY CONTACT INFO

CURRENT MEDICATION (INCLUDE VITAMINS, OVER-THE COUNTER MEDICATION, ETC)

LIST OF ANY MAJOR ILLNESSES

LIST ANY SURGERIES:

RESPIRATORY SYSTEM

BLOOD AND CIRCULATORY SYSTEM

ENDOCRINOLOGY SYSTEM

CARDIAC SYSTEM

HEPATIC SYSTEM

AUTO IMMUNE SYSTEM

DIGESTION PROBLEMS

MENTAL HEALTH

TOBACCO/ALCOHOL USAGE

BONE OR JOINT PROBLEM

DIET HISTORY

REVIEW OF SYSTEMS