Survey

CLIENT INFORMATION:

CLIENT INFORMATION: Patient Name:
D O B & Age:
Address:
Address :
City/Town:
State:
ZIP:
Marital Status:
Email Address
Phone Number:

RACE:

Sex:

Sex: Male

Female

What is your current

What is your current Height?
Weight?

What type of weight loss program are you interested in?

What type of weight loss program are you interested in? Medical Supervised

Coaching

Gastric Bypass Surgery (RNY)

Lap-Band

Gastric Sleeve

Revision - Had weight loss surgery before

Are you currently under a physician's care for weight loss? If yes, please provide:

Are you currently under a physician's care for weight loss? If yes, please provide: Name:
Clinic Name:
Address:
Address 2:
City:
State:
ZIP Code:
Email Address:
Phone Number:

Weight & Eating History

Weight & Eating History How long have you been overweight?
Age began first diet?
Most weight you ever lost?
How was weight loss obtained?
Your favorite foods?
How often do you eat sweets?
Are you a snacker?

DIETARY HISTORY
PLEASE COMPLETE THIS FORM AS PRECISELY AS POSSIBLE

	# Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . Medi-Fast	DIETARY HISTORY PLEASE COMPLETE THIS FORM AS PRECISELY AS POSSIBLE M . D . SUPERVISED . . . Medi-Fast # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . Opti-Fast	M . D . SUPERVISED . . . Opti-Fast # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . Mayo Clinic	M . D . SUPERVISED . . . Mayo Clinic # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . Diet Program	M . D . SUPERVISED . . . Diet Program # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . B-6 Shots	M . D . SUPERVISED . . . B-6 Shots # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . B-12 Shots	M . D . SUPERVISED . . . B-12 Shots # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Lasix Pills (diuretic)	Lasix Pills (diuretic) # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Xenica Pills	Xenica Pills # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Meridia Pills	Meridia Pills # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
LIQUID DIETS Slim-fast	LIQUID DIETS Slim-fast # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
LIQUID DIETS Sweet Success	LIQUID DIETS Sweet Success # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
LIQUID DIETS Protein	LIQUID DIETS Protein # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Low Calorie Diet	Low Calorie Diet # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Low Fat Diet	Low Fat Diet # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
High Protein Diet	High Protein Diet # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Self-Imposed Fasts	Self-Imposed Fasts # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Richard Simmons	Richard Simmons # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Herbal Life	Herbal Life # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Cambridge Diet	Cambridge Diet # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Atkins Diet	Atkins Diet # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Over the Counter Acutrim	Over the Counter Acutrim # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Over the Counter Dexatrim	Over the Counter Dexatrim # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Over the Counter Metabolife	Over the Counter Metabolife # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Over the Counter Xenadrine	Over the Counter Xenadrine # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Psychotherapy	Psychotherapy # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Accupuncture	Accupuncture # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Hypnosis	Hypnosis # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Subliminal Tapes	Subliminal Tapes # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
EXERCISE Health Club	EXERCISE Health Club # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
EXERCISE Daily Walking	EXERCISE Daily Walking # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
EXERCISE VCR Tapes	EXERCISE VCR Tapes # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained

Other diets not listed above - M.D. SUPERVISED NAME or CLINIC NAME

Heath Conditions
Please mark what applies to you

	Yes	No
Do you get short of breath at rest?	*Heath Conditions Please mark what applies to you Do you get short of breath at rest? Yes	Do you get short of breath at rest? No
Do you get chest pain when exercising?	Do you get chest pain when exercising? Yes	Do you get chest pain when exercising? No
Do you get short of breath when exercising?	Do you get short of breath when exercising? Yes	Do you get short of breath when exercising? No
Do you experience irregular or excessively strong heartbeats?	Do you experience irregular or excessively strong heartbeats? Yes	Do you experience irregular or excessively strong heartbeats? No
Do you sleep lying flat?	Do you sleep lying flat? Yes	Do you sleep lying flat? No
Do you wake up at night short of breath?	Do you wake up at night short of breath? Yes	Do you wake up at night short of breath? No
Have you had any blackouts?	Have you had any blackouts? Yes	Have you had any blackouts? No
Do you get swollen ankles?	Do you get swollen ankles? Yes	Do you get swollen ankles? No
Have you had easy or excessive bleeding from surgery	Have you had easy or excessive bleeding from surgery Yes	Have you had easy or excessive bleeding from surgery No
or minor injuries?	or minor injuries? Yes	or minor injuries? No
Have you had easy bruising?	Have you had easy bruising? Yes	Have you had easy bruising? No
Do you have heavy periods?	Do you have heavy periods? Yes	Do you have heavy periods? No
Are you still having periods?	Are you still having periods? Yes	Are you still having periods? No

Diagnosed or Treated
Please mark what applies to you

	Yes	No
Have you been diagnosed or treated for high blood pressure?	*Diagnosed or Treated Please mark what applies to you Have you been diagnosed or treated for high blood pressure? Yes	Have you been diagnosed or treated for high blood pressure? No
Have you been diagnosed or treated for diabetes?	Have you been diagnosed or treated for diabetes? Yes	Have you been diagnosed or treated for diabetes? No
Do you have high blood cholesterol?	Do you have high blood cholesterol? Yes	Do you have high blood cholesterol? No
Do you have high blood fats or triglycerides?	Do you have high blood fats or triglycerides? Yes	Do you have high blood fats or triglycerides? No
Have you ever been diagnosed with asthma?	Have you ever been diagnosed with asthma? Yes	Have you ever been diagnosed with asthma? No
Have you been diagnosed or treated for heartburn or gastro-esophageal reflux (GERD)?	Have you been diagnosed or treated for heartburn or gastro-esophageal reflux (GERD)? Yes	Have you been diagnosed or treated for heartburn or gastro-esophageal reflux (GERD)? No
Have you ever had stomach ulcers?	Have you ever had stomach ulcers? Yes	Have you ever had stomach ulcers? No
Have you ever had blood clots in your leg veins?	Have you ever had blood clots in your leg veins? Yes	Have you ever had blood clots in your leg veins? No
Have you ever been anemic?	Have you ever been anemic? Yes	Have you ever been anemic? No
Have you ever had iron deficiency or taken iron?	Have you ever had iron deficiency or taken iron? Yes	Have you ever had iron deficiency or taken iron? No
Have you ever been diagnosed with hypothyroidism?	Have you ever been diagnosed with hypothyroidism? Yes	Have you ever been diagnosed with hypothyroidism? No
Have you ever had thyroid surgery?	Have you ever had thyroid surgery? Yes	Have you ever had thyroid surgery? No
Do you take thyroid replacement medication?	Do you take thyroid replacement medication? Yes	Do you take thyroid replacement medication? No

CLIENT PRIMARY CARE PHYSICIAN NAME:

CLIENT PRIMARY CARE PHYSICIAN NAME: Physician Name:
Address:
City/Town:
State:
ZIP:
Phone Number:

May we send your PRIMARY CARE PHYSICIAN information about your case?

May we send your PRIMARY CARE PHYSICIAN information about your case? Yes

No

List any medical problems you have for which you have seen a doctor or have been hospitalized.

List any medical problems you have for which you have seen a doctor or have been hospitalized. (1) ILLNESS / Date
Treatment
Outcome
(2) ILLNESS / Date
Treatment
Outcome
(3) ILLNESS / Date
Treatment
Outcome
(4) ILLNESS / Date
Treatment
Outcome
(5) ILLNESS / Date
Treatment
Outcome

Surgeries
Please mark what applies to you

	Yes	No
Does your religion prohibit you from receiving blood products?	*Surgeries Please mark what applies to you Does your religion prohibit you from receiving blood products? Yes	Does your religion prohibit you from receiving blood products? No
Have you had your gallbladder removed?	Have you had your gallbladder removed? Yes	Have you had your gallbladder removed? No
Have you had a hysterectomy?	Have you had a hysterectomy? Yes	Have you had a hysterectomy? No
Have you had a tubal ligation or had your “tubes tied”?	Have you had a tubal ligation or had your “tubes tied”? Yes	Have you had a tubal ligation or had your “tubes tied”? No
Have you had WEIGHT LOSS SURGERY before?	Have you had WEIGHT LOSS SURGERY before? Yes	Have you had WEIGHT LOSS SURGERY before? No

If Yes when and what type of surgery

List all surgeries and specify if done open or laparoscopically.

List all surgeries and specify if done open or laparoscopically. (1) Surgery / Date
Reason / Open-Lap
(2) Surgery / Date
Reason / Open-Lap
(3) Surgery / Date
Reason / Open-Lap
(4) Surgery / Date
Reason / Open-Lap
(5) Surgery / Date
Reason / Open-Lap

Other Medications

	Yes	No
Do you take aspirin on a daily basis?	*Other Medications Do you take aspirin on a daily basis? Yes	Do you take aspirin on a daily basis? No
Do you take Plavix?	Do you take Plavix? Yes	Do you take Plavix? No
Do you take Coumadin?	Do you take Coumadin? Yes	Do you take Coumadin? No
Do you take Prednisone or Dexamethasone?	Do you take Prednisone or Dexamethasone? Yes	Do you take Prednisone or Dexamethasone? No

List all current medications, including prescriptions, vitamins, over-the-counter, and intermittently used drugs.

List all current medications, including prescriptions, vitamins, over-the-counter, and intermittently used drugs. (1) Medication Name
Strength/How Taken
Purpose/Started
(2) Medication Name
Strength/How Taken
Purpose/Started
(3) Medication Name
Strength/How Taken
Purpose/Started
(4) Medication Name
Strength/How Taken
Purpose/Started
(5) Medication Name
Strength/How Taken
Purpose/Started
(6) Medication Name
Strength/How Taken
Purpose/Started
(7) Medication Name
Strength/How Taken
Purpose/Started

Allergies to Medication

Allergies to Medication (1) Medication
Explain Reactions
(2) Medication
Explain Reactions
(3) Medication
Explain Reactions
(4) Medication
Explain Reactions

RELEASE OF MY MEDICAL INFORMATION

RELEASE OF MY MEDICAL INFORMATION YES,I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY INSURANCE CLAIMS.

Do you sleep with a C-Pap or Bi-Pap?

Do you sleep with a C-Pap or Bi-Pap? Yes

No

SLEEP APNEA SELF TEST

The quiz is designed to alert you to any problems resulting from poor sleep. Answer if you have had any symptoms in the past year; type the symptom number in box and add up the total at the end of the test.

SLEEP APNEA SELF TEST The quiz is designed to alert you to any problems resulting from poor sleep. Answer if you have had any symptoms in the past year; type the symptom number in box and add up the total at the end of the test. (+20) I have been told that I snore or I know that I snore.
(-50) I definitely do not snore.
( +0) I do not know if I snore.
(+10) I have been told that I stop breathing when I sleep.
(+10) I wake up choking.
(+5 ) I sweat excessively at night.
(-5 ) If female and above is true, I have hot flashes related to my cycle.
(+2 ) I am tired and sleepy during the day even after 8 hours of sleep.
(+2 ) I wake up tired and unrested.
(+10) I suddenly wake up unable to breathe.
(+5 ) I have fallen asleep while driving.
(+5 ) I am a restless sleeper, I toss and turn a lot.
(+20) My neck circumference is more than 17 inches,ask office staff to measure if unknown
(+5 ) I frequently have morning headaches.
TOTAL UP SYSTEM NUMBERS. If more than 30 points suggests that you have SLEEP APNEA and should undergo a sleep study.

Psychiatric Treatment

Psychiatric Treatment Have you ever received psychiatric treatment?
Diagnosis or reason for treatment?
Last treatment date?
Treated By: Psychiatrists Psychologists - Physician
Physician's Name:
Address:
Phone number:

ARE YOU RECEIVING DISABILITY BENEFITS?

ARE YOU RECEIVING DISABILITY BENEFITS? Yes	No
If you answered YES to receiving disability benefits, REASON FOR DISABILITY?

CLIENTS EMPLOYER:

CLIENTS EMPLOYER: Job Title:
Company Name:
Address:
City/Town:
State:
ZIP:
Work Phone:

IN CASE OF EMERGENCY:

IN CASE OF EMERGENCY: Contact Person:
Relationship:
Address:
City/Town:
State:
Zip:
Home Phone
Cell Phone:

Pre-Insurance Verification

Only fill this protion if you would like for the Weight Loss Specialists Insurance Department to pre-verify your health insurance for benefits.

While every health insurance policy is unique, it is important to understand your coverage. Read your insurance policy in detail, including what it covers and what it excludes. If your insurance company denies your request, you may be able to appeal the decision.
If you have any other questions you are more than welcome to call our Insurance Department.

Health Insurance Company:

Health Insurance Company: Name:
Address:
City:
State / ZIP:
Phone Number:
Renewal Date:
Policy Number:
Group Number:

Insurance Policy Holder Information

Insurance Policy Holder Information Policy Holder's Name:
Policy Holder's D O B:
Occupation:
Social Security:
Relationship:
Address:
City:
State / Zip
Email Address:
Phone Number:

How did you hear about Weight Loss Specialists?

*
Would you like to be added to our monthly newsletter by email.

Would you like to be added to our monthly newsletter by email. Yes

No

Email address for your monthly newsletter

DIGITAL SIGNATURE: I have provided complete and accurate information to the best of my knowledge. Typing my name and today's date in the box below will serve as my digital signature. (NOTE: If you are under 18, please have a parent or guardian sign as well).
Your digital signature allows us to start processing your case.

DIGITAL SIGNATURE: I have provided complete and accurate information to the best of my knowledge. Typing my name and today's date in the box below will serve as my digital signature. (NOTE: If you are under 18, please have a parent or guardian sign as well). Your digital signature allows us to start processing your case. Patient Signature - Date
Parent Guardian - Date

To be Signed & Dated in person at the time of your first appointment or seminar.

To be Signed & Dated in person at the time of your first appointment or seminar. Patient SIGNATURE and DATE
PARENT or GUARDIAN SIGNATURE and DATE (if patient is under 18 years)

Health History Form