IGIC MWM Intake Form

Integrated Gastroenterology Consultants Weight Management Program

NEW PATIENT MEDICAL HISTORY FORM
First Name*
Last Name*
Date of Birth*
Email*
example@example.com
An email address is required for ALL program attendees
Phone: (Home)
(Cell)*
Primary Care Provider (PCP)*
Approximate date of last physical exam:*
Health Insurance Name*
Health Insurance ID #*
Policy Holder Name, If other than Self (Spouse/ Parent):
Which of the following would you like to participate in (you may select more than one):*

Medical Weight LossLifestyle Medicine (non-pharmacologic)Weight Loss Surgery
Current Height*
Current Weight:*
Current BMI*
Leave blank if you're not sure.
* Please note, only accepting patients with a BMI > 30 or > 27 with a comorbidity.
Do you have any of the following lifestyle-related medical conditions? (check all that apply)*

High Blood PressureHigh CholecterolHigh TriglyceridesPrediabetesType 2 DiabetesSleep ApneaFatty LiverOther
Past Medical History (Select all that apply):

Heart AttackGERDPancreatitisBipolarLiver DiseaseStrokeThyroid DisorderInfertilityGlaucomaKidney StonesAnginaCeliac DiseaseArthritisMigrainesBlood ClotsGallstonesAnxietyPCOSSeizuresGestational DiabetesSleep ApneaDepressionGoutKidney Disease
Frequent use of steroids (e.g., prednisone, Medrol Dosepak)? Yes/ No?*
Do you have a history of cancer? (type/s)*
Do you currently see any of the following providers (circle all that apply)?

Psychologist/ CounselorCardiologistPsychiatrist (med prescriber)PulmonologistEndocrinologistNephrologist
Allerigies*
Past Surgical History

Gastric BandingGall BladderGastric SleeveHeart BypassGastric BypassHysterectomyOther
Gastric Banding Date
Gallbladder Date:
Gastric Sleeve Date:
Heart Bypass Date:
Gastric Bypass Date:
Hysterectomy
Smoking

NeverCurrentPast Smoker
Current Smoker: Packs per day
Former Smoker: How long ago did you quit?
Use of drugs?

NeverCurrentPast
Type of drugs
Marijuana

NeverCurrentOther
Highest Level of Education

High SchoolAssociatesBachelorsMaster'sDoctoral
Marital Status

SinglePartnerMarriedSeperatedDivorcedWidowed
Do you have children?
Children Names and Ages
Who lives at home with you?
Employment

EmployedUnemployedDisabledRetired
Occupation
Family History

High Blood PressureHeart DiseaseHigh CholesterolAlcohol/ Drug AbuseStrokeThyroid ProblemsAnxietyDepressionCancerOther
Family History Cancer Type/s
How does your weight affect your life and health?*
What is motivating you to lose weight at this time?*
Do you have any specific goals beyond weight loss (e.g., reduce pain, increase energy, reverse a chronic disease)*
When was the last time you felt good in your body?*
How important is losing weight to you? (please select one)

Not importantSomewhat importantModerately importantImportantVery Important
What habits are you most motivated to change at this time?*
How confident are you that you can make healthy behavior changes? (scale of 1 10)*
What makes it challenging for you to have healthy lifestyle habits?*
How have you overcome similar challenges in the past?*
Do you feel you have support trying to lose weight (i.e., family, friends, co-workers, etc)
Do you feel you have support: If no, why not?*
When did you first notice that you were gaining weight (please pick one)*

ChildhoodTeensAdulthoodPregnancyMenopause
Do you have a family history of obesity*
How much did you weigh: One year ago?*
How much did you weigh: Five years ago?*
How much did you weigh: Ten years ago?*
What is the most you have ever weighed (outside of pregnancy) and when was this?
Life events associated with weight gain (select all that apply)*

MarriageInjuryDrugsDivorceNight Shift WorkSurgeryAbuseJob ChangeMenopauseIllnessQuit SmokingTravelAlcohol
Weight Promoting Medication (please list)*
Previous weight-loss programs tried? (circle all that apply)*

Weight WatchersAtkinsDASH DietOrnish DietHMRNutrisystemSouth BeachPaleoKeto DietHerbalifeJenny CraigZone DietHCG DietIntermittent FastingDiet WorkshopLA WeightlossMedi Weight LossMediterranean DietProtein ShakesOptaviaOther
What was your maximum weight loss?*
Which, if any, of the above programs were successful?*
What you every taken any of the following? (select all that apply)

Phentermine (Apidex)BelviqNaltrexoneMounjaroXenical/ AlliQsymiaSaxendaTrulicityPhen/FenContraveOzempicMetforminTopiramate (Topamax)Bupropion (Wellbutrin)WegovyOther
What worked? (medication)
What didn't work and why?*
Do you or have you ever tracked food intake? *
Who does food shopping/ cooking at home?*
Do you regulary prepare food ahead of time?*
How often for you eat breakfast (days per week)*
Time of breakfast AM*
Number of meals do you eat per day?*
Do you consume sugary drinks? (juice, soda, etc.)*
Do you drink diet or artificially sweetened beverages?*
How many glasses of water do you drink on a typical day?*
Do you drink alcohol?*
How many Alcohol drinks per week?*
Do you ever consume more than 5 alcoholic drinks per day?*
Prior treatment for alcoholism?*
List any food intolerances/ allergies/ sensitivities*
Please provide a 24 hour diet history (i.e. list everything you might eat or drink in a typical day)*
The quality of your food choices on average? (pick one)*

ExcellentGoodFairPoor
How many times a week do you eat meals not prepared at home?*
Do you struggle with any of the following*

Always hungryLate night eatingMeal skippingOvereating/ large portionsEmotional EatingUnder eatingCravings (salty/sweet)Binge EatingSocial Outings
Do you frequently do others things while eating? (watch TV, Reading)*
Do you get up in the middle of the night to eat?*
Do you get up in the middle of the night to eat? how often?*
Do you ever feel out of control while eating?*
Have you ever been diagnosed with an eating disorder?*
If yes, which one?*
Did you ever received professional treatment (for eating disorder)*
Have you ever seen a dietitian?*
Have you ever seen a dietitian? If yes, when?*
Are you interested in a dietician referral?*
How motivated are you to make changes to your eating habits (scale of 1 10)?*
Do you exercise regularly?*
Exercise type*
Duration of exercise hours?*
Duration of exercise minutes?*
Duration of exercise Number of times per week*
What barriers, if any, do you have to exercise?*
How motivated are you to make changes to your exercise habits (scale of 1 10)?*
Stress level (scale of 1 10)*
Current Stressors*
What, if any, mindfulness techniques do you practice (e.g., meditation, deep breathing, guided relaxation, etc.)*
How motivated are you to make changes to your stress management (scale of 1 10)?*
Have you every been hospitalized for mental health?
How many hours of sleep do you average per night?*
Do you have trouble falling asleep*
Do you wake up frequently or have trouble staying asleep?*
Do you wake up feeling refreshed?*
Do any of the following apply to you? (Select all that apply)*

Sleep Study CompletedSleep Apnea DiagnosisUse of a CPAP
What else would you like your health care provider to know about you?*
Should be Empty: