• Vital Weight Loss MD

    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

  • Today's Date
  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • INTERESTED IN LEARNING ABOUT: Check all that applies*
  • Is your weight?*
  • PRESENT DIET & ACTIVITIES:*
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  • PRIOR TREATING DOCTORS
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  • PRIOR WORKUP FOR PRESENTING PROBLEMS: Have you had?*
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  • PAST TREATMENTS FOR WEIGHT: Have you had?*
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  • PAST MEDICAL HISTORY:*
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  • Have you had any PAST SURGERIES?*
  • LIST ANT PAST SURGERIES:
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  • FAMILY HISTORY: Does any family members suffer from:
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  • SOCIAL HISTORY:*
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  • Do you have any DRUG ALLERGIES?*
  • LIST ALL ALLERGIES TO DRUGS OR ANESTHESIA:
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  • Are you taking any MEDICATIONS or Over-the-counter Supplements/Herbs?*
  • LIST THE MEDICATIONS or Over-the-counter Supplements:
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  • Have you tried any medications previously for your problems?*
  • List PAST DRUGS attempted for your problem:
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  • REVIEW OF SYSTEMS (General Health Questions): Do you have any problems with:*
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  • Today's Date
  • Should be Empty: