New Life Patient Weight Loss & Medical History Questionnaire

New Life Patient Weight Loss & Medical History Questionnaire
Name*

First NameLast Name
MaleFemale
DOB*

MonthDayYear
Date
Home Phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Current Weight:*
Current Height:*
BMI:
INSURANCE INFORMATION
Insurance Name*
YesNo
If so what Pre-Approval Requirements do they have ?
Pre-Op weight loss required? How many lbs?
YesNo
If a Medically Supervised Weight Loss Program is required, what is the length of time required?
Duration of Obesity?
YesNo
YesNo
YesNo
Other Requirements?
PREVIOUS ATTEMPTS AT WEIGHT REDUCTION:
How many years have you been overweight?
Estimated weight at Birth?
Estimated weight at Marriage?
Lowest Weight in Past 5 Years?
Highest Weight in Past 5 Years?

PREGNANCY WEIGHT?

Rate the following foods from 1-5. 1 for Don't Like Very Much, and 5 for Live Very Much (most likely to make you go off a diet).

Please indicate which of the following diets or plans you have tried:

Please indicate if you have taken any of the following medications to lose weight:

Rows	Dates	Duration	MD Supervised?	Weight Loss
Amphetamines
Phentermine (Adipex, Fastin, Pondimen)
Phen-Fen
Dexfenfluramin (Redux)
Xenical (Orlistat)
Meridia (Sibutramin)
Ozempic/ Wegovy
Mounjaro / Zepound

Please indicate if you have tried any of the following weight loss therapies:

Tell us about your previous weight loss surgery:

Rows	Type	Date	Surgeon	Weight Loss
Surgery

Non-Dietary Therapy