New Weight Loss Patient
Patient Information Sheet
Name
*
First Name
Middle Name
Last Name
Date of Birth (DOB)
*
-
Month
-
Day
Year
Date
Date
*
/
Month
/
Day
Year
Date
Birth Sex
*
M
F
Are you currently pregnant or breastfeeding?
*
No
Yes
Cell Phone
*
Marital Status
*
Single
Married
Widowed
Divorced
Email Address
*
example@example.com
Opt into email updates?
Yes
No
Address
*
Street Address
Street Address Line 2
City
State
Zip
How did you hear about gerstenberg.clinic?
Word of Mouth
Google
TV
Yard Sign
Facebook
Other
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In Case of Emergency
Emergency Contact First Name
*
Emergency Contact Last Name
*
Phone
*
Relationship to you
*
Signature of Patient or Guarantor:
*
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Motivation
What are your primary goals for living a healthier lifestyle? (check all that apply)
Weight loss
Falling asleep faster / Better quality of sleep
Having more energy / Feeling better overall
Feeling more clear-headed
Relief from chronic pain / headaches & migraines
Relief from constipation
Feeling less bloated
Relief from loose bowels
Find foods that may be causing digestion issues
Having less "sick days" / Better immune system health
Lower blood pressure
Type option 12
Combatting one or more of the following (check all that apply)
Seasonal Allergies
Asthma
Type II Diabetes
Eczema
Adult Acne
Arthritis
High Blood Pressure
Other
Do you have any comments or explanation?
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Personal Health
Food Habits and Needs
Are you a diabetic?
*
Yes
No
Unsure
Do you consider yourself to be healthy?
*
Yes
No
Do you feel that you eat nutritious foods most of the time?
*
Yes
No
How many meals and/or snacks do you have per day?
*
What are your favorite restaurants?
*
What restaurants do you visit most frequently?
*
What is your favorite type of food/comfort food?
*
How often do you cook at home?
*
5-7 times/week
3-4 times/week
1-2 times/week
Rarely/Never
Do you cook for other household members?
*
Yes
No
How many?
*
Do you have any allergies or dietary restrictions?
*
Yes
No
Please explain your dietary restrictions
*
Do you need to daily monitor sugar, salt, or fluid intake?
*
Yes
No
Have you ever had surgery for weight loss?
*
Yes
No
Please explain your surgery
*
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Personal Health
Lifestyle
What makes you feel stressed?
*
What are your leisure activities?
*
What is your current occupation?
*
Do you work night shifts?
*
Yes
No
Does your job require that you sit at a desk?
*
Yes
No
Do you have a regular sleep schedule?
*
Yes
No
What time do you normally go to bed?
*
Hour Minutes
AM
PM
AM/PM Option
What time do you normally wake up?
*
Hour Minutes
AM
PM
AM/PM Option
On average, how many hours of sleep do you get each night?
*
In the past year, how often do you exercise?
*
5-7 times a week
3-4 times a week
1-2 times a week
None
Are you currently involved in regular exercise?
*
Yes
No
Do you have any issues with mobility?
*
Yes
No
Please explain
*
What are your personal barriers to exercise?
*
What type of physical activity do you consider fun?
*
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Personal Health
Attitude
Do you have any negative feelings toward, or have you had any bad experiences with a nutrition or exercise program?
*
Yes
No
Please explain:
*
Specifically describe what you would like to accomplish through monitoring your health during the next 1 month:
*
Specifically describe what you would like to accomplish through monitoring your health during the next 4 months:
*
Specifically describe what you would like to accomplish through monitoring your health during the next 1 YEAR:
*
To improve your health in the past, what programs, "diets" supplements, medications, or professionals have you had SUCCESS with?
*
Do you start a plan and find it hard to stick to?
*
Yes
No
Are you read to commit to a plan?
*
Yes
No
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Adult Past Medical History
Check all that apply
Seasonal or food allergies
Asthma
Bronchitis
Chronic lung disease (COPD)
Carotid artery blockage
Stroke
TIA
Congenital heart disease
Congestive heart failure (CHF)
Heart disease
High blood pressure or hypertension
Blood vessel disease or blood clots
High cholesterol
Diabetes
Thyroid disease
Describe Congenital heart disease
*
Heart Disease Type
*
Specify blood vessel condition
*
Diabetes - Type
*
Type 1
Type 2
Thyroid disease – Type
*
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Adult Past Medical History
Check all that apply
Heartburn
Reflux
Stomach ulcers
Headaches
Migraines
Anemia
Liver disease
Colon disease
Bladder/Kidney disease
Anemia - Type
*
Liver Disease - Type
*
Colon Disease – Type
*
Bladder/Kidney disease – Type
*
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Adult Past Medical History
Check all that apply
Alzheimer's Disease/Memory trouble
Seizures
Muscle disorder
Joint trouble/arthritis
Sickle cell
Skin disease
Cancer
Autoimmune
Other
Muscle disorder type
*
Joint trouble/arthritis – Type (for example: Osteoarthritis)
*
Skin disease – Type
*
Cancer – Type
*
Autoimmune - Type
*
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Surgeries -Check all that apply
*
NONE
Tonsils
Appendix
Gallbladder
Tubal ligation
Hysterectomy
Other
Additional surgeries and dates:
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Please list all members of household, and relationship
*
Do you have known drug allergies?
*
No known allergies
Yes
List ALL drug allergies
*
Do you consume alcohol?
*
Yes
No
How much alcohol and how often do you use it?
*
Do you use tobacco?
*
Yes
No
Type of tobacco used? (Vape, cigarette, dip etc)
*
How long have you used tobacco?
*
Date of Last menstrual period
*
Birth control, if any
*
Do you have a living will?
*
Yes - if yes, please provide a copy for our records
No
List all medications and supplements you are currently taking - name, dosage and instructions. Please bring your bottles each visit for clarification!
Employment status
*
Employed
Retired
Unemployed
Employer
*
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Family History
Does/did your Father have any of these conditions?
Heart attack
Heart disease (other than heart attack)
High blood pressure
High cholesterol
Stroke or TIA
Sudden death
Thyroid disease
Cancer
Diabetes
Other
Father's Heart disease Type
*
Father's Thyroid disease Type
*
Father's Cancer Type
*
Father's Diabetes Type
*
Does/did your Mother have any of these conditions?
Heart attack
Heart disease (other than heart attack)
High blood pressure
High cholesterol
Stroke or TIA
Sudden death
Thyroid disease
Cancer
Diabetes
Other
Mother's Heart Disease Type
*
Mother's Thyroid disease Type
*
Mother's Cancer Type
*
Mother's Diabetes Type
*
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Father's Parent's Medical History
Does/did your Paternal Grandfather have any of these conditions?
Heart attack
Heart disease (other than heart attack)
High blood pressure
High cholesterol
Stroke or TIA
Sudden death
Thyroid disease
Cancer
Diabetes
Other
PGF Heart Disease Type
*
PGF Thyroid disease Type
*
Paternal Grandfather's cancer type
*
PGF Diabetes Type
*
Does/did your Paternal Grandmother have any of these conditions?
Heart attack
Heart disease (other than heart attack)
High blood pressure
High cholesterol
Stroke or TIA
Sudden death
Thyroid disease
Cancer
Diabetes
Other
PGM Heart Disease Type
*
PGM Thyroid Disease Type
*
Paternal Grandmother's cancer type
*
PGM Diabetes Type
*
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Mother's Parents Medical History
Does/did your Maternal Grandfather have any of these conditions?
Heart attack
Heart disease (other than heart attack)
High blood pressure
High cholesterol
Stroke or TIA
Sudden death
Thyroid disease
Cancer
Diabetes
Other
MGF Heart Disease Type
*
MGF Thyroid Disease Type
*
Maternal Grandfather's cancer type
*
MGF Diabetes Type
*
Does/did your Maternal Grandmother have any of these conditions?
Heart attack
Heart disease (other than heart attack)
High blood pressure
High cholesterol
Stroke or TIA
Sudden death
Thyroid disease
Cancer
Diabetes
Other
MGM Heart Disease Type
*
MGM Thyroid Disease Type
*
Maternal Grandmother's cancer type
*
MGM Diabetes Type
*
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