Weight Questionnaire

Vital Weight Loss MD

Vital Total Health Medical Group, Inc.
710 S Broadway, Ste 212, Walnut Creek, CA 94596

4200 18th Street, Ste 103A, San Francisco, CA 94114

2929 Summit Street, Ste 103A, Oakland,CA 94609

4439 Stoneridge Drive, Ste 110, Pleasanton, CA 94588

6611 Folsom-Auburn Road, Ste F, Folsom, CA 95630

291 S La Cienaga Blvd, Ste 108, Beverly Hills, CA 90211

www.VitalTotalHealth.com www.VitalOncall.com

Walnut Creek 925-464-1580

Pleasanton 925-750-8595

Oakland 510-990-0830

San Francisco 415-915-5100

Folsom 916-287-8411

Beverly Hills 323-917-2500
WEIGHT QUESTIONNAIRE
Patient Name*
Today's Date
Date of Birth:*

MonthDayYear
Date
Age*
Height*
Weight*
Target Weight*
INTERESTED IN LEARNING ABOUT: Check all that applies*

Diet PlanExercise ProgramDiet MedicationsHormone Replacement TherapyBody sculptingSurgical Options
Chief Complaint or Concern #1.*
Chief Complaint or Concern #2.
Chief Complaint or Concern #3.
Date of Onset and Description of Concerns:*
Is your weight?*

Staying the same.IncreasingDecreasing

PRESENT DIET & ACTIVITIES:*

	Yes	No
Are you presently on a Diet Plan?
Are you presentlly doing any exercises?
Do you belong to a gym?
Do you use Home Exercise Equipment? Bicycle or Treadmill?

PRIOR TREATING DOCTORS

PRIOR WORKUP FOR PRESENTING PROBLEMS: Have you had?*

	No	Yes	Month & Year	Findings
Labs
Body Analysis

PAST TREATMENTS FOR WEIGHT: Have you had?*

	No	Yes	Month/Year	Did it help?
Diet Program
Exercise Program
Diet pills
Hormone Replacement Therapy
Body Sculpting or Contouring
Surgery

PAST MEDICAL HISTORY:*

	Yes	No
Seizures
Stroke
Glaucoma
Thyroid Disease
Diabes
Hypertension
High Cholesterol
Heart disease or Irregular Rhythm
COPD or Emphysema
Asthma
GERD or Reflux Gastritis
Pancreatitis
Hepatitis or Gallbladder
Kidney problems
Prostate enlarged, prostatitis
Pelvic/Genital problems
Arthritis
Chronic Pain
Chronic Infection
Cancer
Addiction
Depression
Anxiety
ADHD

LIST ANT PAST SURGERIES:

FAMILY HISTORY: Does any family members suffer from:

SOCIAL HISTORY:*

	Yes	No
Are you married or live with a person?
Do you live with other people?
Do you have children?
Do you smoke cigarettes?
Do you drink alcohol daily?
Do you use any street drugs?

LIST ALL ALLERGIES TO DRUGS OR ANESTHESIA:

	Drug Name	Reaction (Rash, Swelling, shortness of breathe)
Drug #1
Drug #2
Drug #3

LIST THE MEDICATIONS or Over-the-counter Supplements:

List PAST DRUGS attempted for your problem:

REVIEW OF SYSTEMS (General Health Questions): Do you have any problems with:*

	Yes	No
Fever. Chills. Swelling.
Sleep less than 6 hours.
Headaches. Migraines.
Difficulties in Vision.
Difficulties in Hearing.
Nasal or sinus congestion. Nose bleeds. Unable to smell or taste.
Problems with teeth or gums. Sore throat. Swollen glands.
Chest pain. Rapid or irregular heart beats. Feet swelling.
Shortness of Breath.
Wheezing. Coughing.
Nausea. Vomiting.
Heartburn. Abdominal pain.
Yellow jaundice.
Diarrhea. Constipation.
Bright red blood in stool. Dark stool.
Poor libido.
Pelvic pain.
Sexual Dysfunction (ED in men, FSD in women)
Frequent urination. Burning. Urgency. Weak urine flow.
Wake up to urinate.
Weakness. Fatigue.
Joint pain. Muscle pain.
Problems with Balance.
Skin rashes. Acne. Moles. Easing bruising.
Hair loss.
Numbness. Tingling.
Seizures.
Forgetful.
Repeatedly or overly worried. Rapid thoughts.
Trouble falling asleep.
Snoring.
Feeling sad or depressed.
Feeling hopeless. Suicidal thoughts.
Weight Loss. Poor Appetite
Weight Gain. Excessive Appetite.

Vital Weight Loss MD