Fit Familia Weight Management Program

To the best of your ability, please provide the following weight history:
What did you weigh 1 year ago?Weight in pounds   
What did you weigh 5 years ago?Weight in pounds       
What did you weigh 10 years ago?Weight in pounds     

If known, what is your current weight? Weight in pounds   
How tall are you?   ft' in"   

How much has your weight changed in the last year?   # in pounds   


Have you started any new medication(s) in the last year? Please Select Yes No    
If yes, what medication?   Medication   
When did you start it?   Date   

Have you taken medication to help with weight loss in the past?    Please Select Yes No   
If yes, what medications have you tried?  
 Medication 1   Medication 2   Medication 3   Medication 4   
What medications were effective for you in the past?
 Medication 1   Medication 2 Medication 3 Medication 4
What medications were ineffective for you in the past?
 Medication 1   Medication 2 Medication 3 Medication 4

Are you currently following a specific diet plan/concept?    Please Select Yes No    
If yes, what diet plan are you following?   e.g. Keto, Atkins, Whole 30, etc   

How many times per day do you eat, including snacks?   Number   
Does your schedule allow you to get 5 meals in per day?    Please Select Yes No    

How much water do you drink in a day?   e.g. 80oz   

How much time can you schedule in your week for meal prep?   e.g. 2 hours


What is your profession?   Profession   
How many hours do you work per week?   # in hours  
Do you work shift work?   Yes   No   No   

24 HOUR DIET RECALL: Please fill in what foods and drinks you have had and what time you had them in the last 24 hours.
Food/Drink   Time AM PM    
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM
Food/Drink   Time AM PM

Do you have chest pain? Please Select Yes No    
If yes, how long have you had this pain? e.g. 6 months
If yes, what makes the pain worse? Answer Answer
If yes, what makes the pain better? Answer Answer

Have you ever had a heart attack?    Please Select Yes No    If yes, answer the following:
When was your heart attack?   MM/YY  
Did you require surgery for your heart attack?    Please Select Yes No     
If so, what type of surgery?   Bypass surgery   Stent placement   Other  

Do you have high blood pressure?    Please Select Yes No    If yes, answer the following:
Do you take medication for high blood pressure?    Please Select Yes No    
If so, list medication(s): Medication 1 Medication 2   Medication 3 
Have you ever been told you have low blood pressure?    Please Select Yes No    

Have you EVER had a blood clot?    Please Select Yes No    
Are you on blood thinners?    Please Select Yes No    
If so, what medicine(s) are you on?   Medication 1   Medication 2   
Do you have high cholesterol?    Please Select Yes No    
Do you get swelling in your legs?    Please Select Yes No    
Do you have varicose veins?    Please Select Yes No    

Do you have shortness of breath?    Please Select Yes No    If yes, answer the following:

Are you short of breath at rest?    Please Select Yes No    
Do you have shortness of breath while walking on a flat surface for less than 5 minutes?    Please Select Yes No    
About how long can you walk on a flat surface before you become short of breath?   5 minutes   10 minutes   30 minutes   60 minutes or more   
Do you know what causes your shortness of breath?    Please Select Yes No    
If so, please explain:   Reason   

Do you have asthma?    Please Select Yes No    
Do you have COPD?    Please Select Yes No    
 
Have you EVER been hospitalized or needed a "breathing tube" placed for breathing problems?    Please Select Yes No    
If yes, when and for what?   Date   Diagnosis   

Have you ever had blood clots in your lungs or a pulmonary embolism?    Please Select Yes No    

Have you EVER been diagnosed with diabetes or pre-diabetes?    Please Select Yes No   
If yes, answer the following:
Do you have type I (juvenile onset) diabetes?    Please Select Yes No     
Do you have type II (adult onset) diabetes?    Please Select Yes No    
Do you have a history of hypoglycemia or low blood sugar?    Please Select Yes No   
Do you take medications for diabetes?    Please Select Yes No     
If yes, what medicine(s) do you take?   Medication 1   Medication 2   
If female, have you ever had gestational diabetes?    Please Select Yes No    

Do you have thyroid problems?    Please Select Yes No    
If yes, what is your diagnosis?   Diagnosis   

If female, do you have PCOS (Polycystic Ovarian Syndrome)?    Please Select Yes No   
If female, have you gone through menopause?    Please Select Yes No    

Do you have heartburn or acid reflux?    Please Select Yes No    
If yes, how often does this happen?   e.g. 3 times per week   
Do you take medicine for heartburn or acid reflux?    Please Select Yes No    
Have you EVER had a stomach ulcer?    Please Select Yes No    

Do you have problems with constipation?    Please Select Yes No    
Do you have problems with diarrhea?    Please Select Yes No    

Have you had your gallbladder removed?    Please Select Yes No    

Have you had bariatric surgery?    Please Select Yes No    
If yes, what surgery did you have and when? SurgeryDate

Do you take anti-inflammatory medications such as ibuprofen, aspirin, or aleve?    Please Select Yes No    
If yes, how much and how often?   e.g. 3 ibuprofen   e.g. once every 2 days  
 
Do you take prescription pain medications?    Please Select Yes No    
If yes, what for?   Diagnosis   
What medication do you take?   Medication name   
What dosage is the medicine?   e.g. 10mg   
How often to you take it?   e.g. every 8 hours   

Have you been diagnosed with kidney disease?    Please Select Yes No    
Have you EVER had kidney failure?    Please Select Yes No    
If so, what from?   e.g. dehydration   
Have you had kidney stones?    Please Select Yes No    

Do you have anxiety or depression?    Please Select Yes No      
If yes, do you take medications for this diagnosis?    Please Select Yes No    
If so, what medicine(s) do you take?   Medication 1   Medication 2   

If you have seizures, do you take medication to prevent them?    Please Select Yes No  
If yes, what medication(s)?   Medication 1    Medication 2   

By signing below, I,   Name , acknowledge understanding that the information collected by Fit Familia LLC and East Slope Family Practice will be used for the purpose of developing, monitoring, and sustaining an individualized, medically supervised, health, wellness, and weight management program. Furthermore, I understand that all such information is confidential and will not be shared with anyone outside of Fit Familia LLC and East Slope Family Practice without my prior written authorization, except in the case of medical emergency to the minimum extent necessary to achieve a safe and effective program.