CONFIDENTIAL MEDICAL HISTORY
The following information is necessary for our counselors to determine your eligibility for the program and establish your needs during the weight loss period. Please answer all questions accurately to the best of your knowledge.
All information will be kept confidential according to HIPAA guidelines. Thank you.
I. PERSONAL INFORMATION DATE:______
Name:______Email: ______Home Phone: ______
Address:______Cell Phone:______
City:______State:______ZIP:______Age: ______Birthdate: ______
Employer:______Occupation: ______
Spouse/Partner Name: ______Employer:______Occupation:______
II.MEDICAL HISTORY
1.Primary Care Physician:______Date of Last Examination: ______
2.Please List ALLMedications You Are Currently Taking (Including Birth Control Pills, Aspirin, Laxatives, Vitamins, Etc.)
Please Include Dosage, Strength, And Frequency:
______
______
______
______
3.Have You Ever Taken ANY Of The Following?Steroids: Yes____ No____ Fertility Drugs: Yes____ No____
Appetite Suppressants: Yes____ No____Chemotherapy: Yes____ No____Hormone Replacement Medication: Yes____ No____
4.Known Medication Allergies:______
5. Other Allergies:______
6.Are You Currently Under A Physician’s Care For Any Medical Condition Requiring Treatment? Yes____ No____
If Yes, Please Describe: ______
______
7. If You Have Had Recent Surgery, Explain:______
______
8.What Other Surgeries Have You Had? (List Year)______
______
9.List Reasons (And Year) For Any Other Hospitalizations Or Major Illnesses: ______
______
10.Are You Now Pregnant Or Breast Feeding?Yes____ No____ Explain:______
11.Are You Currently On Any Specific DietPrescribed or Recommended By Your Physician Or A Dietitian? Yes____ No____ Explain:______
12.Do You Use Tobacco Products? Yes____ No____ If So, What Type/How Often?______
13.Do You Drink Alcohol? Yes____ No____ If So, What Type/How Often? ______
14.Do You Take/Use Recreational Drugs? Yes____ No____ If So, What Type/How Often? ______
III.Please Check If You Have Had Or Been Treated For Any Of The Following. (If Yes, Please Explain):
GASTROINTESTINAL____GERD
(gastroesophageal reflux disease)
____IBS
(irritable bowel syndrome)
____Celiac
____gluten sensitivity
____heartburn
____ulcerative colitis
____Crohn’s disease
____diverticulitis/osis
____dumping syndrome
____gastric bypass
____gastric banding
____gastric sleeve
____other bariatric surgery
____diarrhea
____constipation
____other
RESPIRATORY SYSTEM
____asthma
____COPD
(chronic obstructive pulmonary disease)
____emphysema
____chronic allergy/sinus problems
____other
LIVER AND GALL BLADDER
____hepatitis A/B/C
____elevated liver enzymes
____cirrhosis
____jaundice
____gall bladder disease
____gall stones
____other / KIDNEY
____poor kidney function
____kidney stones
____kidney failure
____nephritis
____kidney/bladder infections
____other
REPRODUCTIVE SYSTEM
____fertility treatment
____premenstrual syndrome
____PCOS
(polycystic ovarian syndrome)
____hysterectomy
partial total
____hormone replacement therapy
____BPH
(benign prostatic hypertrophy)
____other
ENDOCRINE & HEMATOLOGY
____anemia
____anti-coagulant therapy
(blood thinners)
____diabetes mellitus type I
____diabetes mellitus type II
____ insulin dependent?
____hypoglycemia
____hypothyroid
____hyperthyroid
____gout
____metabolic syndrome
____growth problem / CARDIOVASCULAR
____arrhythmia
____hypertension
(high blood pressure)
____irregular pulse
____hypertension
____poor circulation
____CABG
(coronary artery bypass graft)
____MI
(myocardial infarction/heart attack)
____stents/angioplasty
____pacemaker/defibrillator
____atherosclerosis
____coronary artery disease
____other
GENERAL
____cancer
surgery chemo radiation
____fluid retention
____arthritis
osteo rheumatoid psoriatic
____fatigue
____AIDS
____lupus
____fibromyalgia
____eczema
____plantar fasciitis
____recurrent infections
____psoriasis
____joint replacement surgery
____other / PSYCHOSOCIAL
____SAD
(seasonal affective disorder)
____OCD
(obsessive compulsive disorder)
____schizophrenia
____bi-polar disorder
____depression
____anxiety
____anorexia
nervosa bulimia other
____alcoholism
____drug
dependence addiction
____history of abuse
____difficult home environment
____other
NEUROLOGIC SYSTEM
____epilepsy/seizures
____stroke
____syncope/fainting spells
____neuropathy
____MS
(multiple sclerosis)
____brain injury
____brain or spinal tumor
____other
IV.WEIGHT LOSS HISTORY
1.Current Weight: ______
2.What You Would Like To WeighOr What Clothing Size Would You Like To Wear? ______
3.How Long Have You Been Overweight? ______
4.Has Your Physician Recommended That You Lose Weight? Yes____ No____
5.Is Anyone Else In Your Family Overweight? (Spouse, Parents. Etc.)______
6.How Long Have You Been Thinking About Losing Weight?______
7.What Do You Do For Recreation?______
8.Do You Feel That You Have Good Eating Habits?______
9.Do You Exercise? Yes____ No____ If So, What Type/How Often? ______
10.Do You Drink Water? Yes____ No____ If So, How Often? ______
11.Are You Having Any Physical Discomfort Associated With Your Weight? ______
______
12.Previous Methods Of Weight Reduction And Results:______
______
Patient Name: ______Date: ______
13.Is, Or Will Your Spouse/Partner Be Aware That You Are On Our Program? Yes____ No____ N/A____
14.Why Do You Want To Lose Weight? Check All That Apply:
____Special Event____Career____Appearance
____Birthday____Social Life ____Personal Life
____Anniversary____Recreation____Self
____Health____Clothing____Other______
15.What Do You Feel Are Your Primary Challenges/Obstacles In Maintaining A Healthy Lifestyle? ______
______
16.Would You Describe Yourself As A: Check All That Apply
____Emotional Eater____Boredom Eater____Stress Eater____Foodie____Busy Bee (food is a nuisance)
____Couch Potato____Overweight, But Healthy Habits
17. Are You Ready To Make The Commitment To Lose Weight?Yes____ No____
How Did You Hear About Ageless?PLEASE CHECK ONE:BE SPECIFIC
Physician ReferralName:______
Client Referral Name:______
TV StationName:______
Radio StationName: ______
PrintName: ______
Social MediaExplain:______
Event/Health FairExplain: ______
OtherExplain:______
I Understand that The Above Information Will Be Kept Confidential And Is Accurate To The Best of My Knowledge:
Client Signature______Date______
Counselor______Date______
Release of Medical Records- If you would like us to send your medical information to your other healthcare providers.
I hereby give authorization for The Ageless Weight Loss and WellnessCenterto release all pertinent information regarding my past medical history, lab results, and any other confidential chart information to:
______
______
______
May we contact you by email with informative materials helpful to your weight loss and weight management success, and special sales benefits of interest to you, our valued client? Your address will be held in strict confidence and never forwarded or sold to any other organization, required under the Privacy Act. YES NO
______
Please Print Your E-mail Address Clearly
101 Prosperous Place Ste 150 AgelessCenter.net10003 Forest Green Blvd
Lexington, KY 40509 Louisville, KY 40223 859.335.1330 October 2014 502.896.0060