Medical History
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Reason For Visit:
Allergies:
Current Medications:
Past Medical History:
Past Surgical History:
Family Medical History:
Do you smoke cigarettes? If so, how many cigarettes per day?
Do you drink alcohol? If so, how many drinks per day?
Do you use recreational drugs? If so, how often?
Have you ever been sexually active? (Question is for pap smear screening purposes and STD testing)
Yes
No
We are Obesity Medicine Specialists and want to make sure you feel respected during your visit. Do you feel comfortable discussing your weight during your appointment?
Yes
No
If the physician sees you meet criteria, are you interested in weight loss medication (semaglutide- "ozempic" / wegovy, tirzepatide/ mounjaro or other oral options?)
Yes
No
Are you interested in PREP (pre-exposure prophylaxis therapy for HIV)
Yes
No
Are you a vegan/vegetarian?
Yes
No
How many hours do you sleep per night?
< 6
6-8
> 8
How many days in a week do you exercise?
Do you feel stressed, anxious, or depressed most days?
Yes
No
Occupation
Females: When was your last pap smear? Mammogram? Colonoscopy?
Post-menopausal females: Are you interested in bioidentical hormone replacement therapy?
Yes
No
Males: When was your last colonoscopy?
Would you like vaccines during your annual physical?
Yes
No
Advance Care Planning
In the case of an emergency, if my heart stops beating, I would like:
CPR, shocks, ACLS medications
To allow natural death
In the case of an emergency, if I cannot breathe in my own, I would like:
Intubation, respiratory support via a ventilator
To allow natural death
In the case of an emergency, if I am unable to eat, I would like:
Feeding Tube
To allow natural death
Optional: Share one fun fact about yourself!
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