Weight Questionnaire

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

Patient Name *

Today's Date

Date of Birth: *

Date

Age *

Height *

Weight *

Target Weight *

INTERESTED IN LEARNING ABOUT: Check all that applies *

Diet Plan Exercise Program Diet Medications Hormone Replacement Therapy Body sculpting Surgical 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. Increasing Decreasing

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

	Name of Doctor, City and State
Family Doctor
Doctor #1
Doctor #2

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

Have you had any PAST SURGERIES? *

Yes No

LIST ANT PAST SURGERIES:

	Month & Year	Operation Performed	Did it help?
Operation #1
Operation #2
Operation #3
Operation #4

FAMILY HISTORY: Does any family members suffer from:

	Mother	Father	Siblings	Children
Thyroid problems
Diabetes
High blood pressure
Heart disease
Stroke
Arthritis
Autoimmune Disease
Cancer
Addiction
Depression/Psych

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?

Do you have any DRUG ALLERGIES? *

Yes No

LIST ALL ALLERGIES TO DRUGS OR ANESTHESIA:

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

Are you taking any MEDICATIONS or Over-the-counter Supplements/Herbs? *

Yes No

LIST THE MEDICATIONS or Over-the-counter Supplements:

	Medication	Strength	Frequency	For What Condition	Prescribing Physician
Drug #1
Drug #2
Drug #3
Drug #4
Drug #5
Drug #6
Drug #7
Drug #8

Have you tried any medications previously for your problems? *

Yes No

List PAST DRUGS attempted for your problem:

	Medication	Strength	Did it help?	Why did you stop?
Drug #1
Drug #2
Drug #3
Drug #4

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.

Signed *

Clear

Today's Date

Vital Weight Loss MD

WEIGHT QUESTIONNAIRE