WEIGHT MANAGEMENT MEDICINE

PATIENT HISTORY QUESTIONNAIRE

First Name *

Last Name *

Phone *

Email *

Gender

Date of birth

Height (ft/inch)

Weight (lb.)

Body Mass Index (BMI)

Blood Pressure (B/P)

Heart Rate (HR)

Allergies

Smoke

Drink

Do you exercise regularly?

How frequently

Any Medical Condition?

Please list current medication list including any over the counter supplements

Any Surgery

What is your goal weight?

When did you start gaining unwanted weight?

List any supervised or unsupervised weight loss attempts

Did you have bariatric surgery?

Describe When

What specific Food Plan/Diet are you currently following, If any?

How many meals do you consume per day?

Do you snack between meals?

How often

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