Dr S Weightloss & Wellness, PLLC

Demographics

Patient Full Name, Phone Number, and Email Address * Date of Birth * Gender Race Address * Zip Code Insurance Name * Policy Number/Member ID * Group Number Coverage Start Date

If the insured is not the patient:

Insured's Full Name, DOB, Gender, Address and Relationship to Patient Social Security Number Secondary Insurance Info Emergency Contact: Name, relationship and phone number * * Name and address of your Pharmacy * Name, phone and fax number of your Primary Care Provider and Referring provider *

Labs

When was the last time you had blood work? * Where at? * Name and Fax number where you had your last Labs *

If you can ask them to fax them to us at: 252-364-8874

test

New Patient Medical History

Medical Problems

Check all that apply * Please list any other medical problem

Allergies

List any allergies to medications or food *

Social History

Check all that apply *

Surgeries

Check all that apply * Please list any other surgery

Medications

list all current medications with the doses, including over-the-counter medications, supplements, and herbs. Bring them to your appointments. *

Family History

List any family h/o Obesity, Diabetes, Heart disease or other disease and specify who

System Review

Check all that apply *

IF YOUR VISIT IF FOR WEIGHT LOSS

Weight History

What is you weight loss goal? Weight gain started during or associated with: * Weight gain >20 lbs in less than 3 months? If yes, when? How much did you weigh: one year ago? Five years ago? 10 years ago? Previous weight-loss programs (check all that apply) * What are your greatest challenges with dieting? Medications taken to lose weight * What worked and what didnt work? Have you ever had weight loss surgery? * What was your maximum weight loss?

Nutritional History

How many days a week do you eat breakfast? How many meals do you eat per day? Which meal is your biggest? * How many meals per week do you eat in restaurant/order take out? * How often do you have sugary drinks? and how much? * How much alcohol do you drink in one week? Binge eating: Do you eat large volumes in a short time or do you feel out of control when eating? * Is night eating a problem for you? * Food cravings * Favorite foods Food triggers (check all that apply) *

Exercise/Physical Activity

Type Duration and Frequency

Sleep

Number of hours/24 hr * Previous sleep study? * Have you been diagnosed with sleep apnea? *

*If YES, skip this section. Using the following scale, please rate your sleepiness on items a-h. 0 = Never Dose. 1 = Slight Chance of Dozing. 2 = Moderate Chance of Dozing. 3 = High Chance of Dozing

a. Sitting and reading b. Watching TV c. Sitting, inactive in public d. Car passenger (for 1 hour) e. Lying down in the afternoon f. Sitting and talking with someone g. Sitting quietly after lunch (no alcohol) h. Stopped for a few minutes in traffic

Food Diary

Describe a typical day with meals, snacks, and beverages:

Breakfast Lunch Dinner Snacks

If Female:

Contraception Breastfeeding