Weight Loss - Health Profile
First Name
Last Name
City
State
Postal code
Address
Email
Phone
Profession
Referral
Current weight (LB)
Weight 1 Year ago (LB)
Minimum adult weight (LB) at age:
Maximum adult weight (LB) at height:
Do you exercise ?
YES
NO
What kind of exercise?
How often ?
Daily
Weekly
Have you been on diet before ?
YES
NO
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Please specify on which diet and why you think it did not work for you
What is your marital status?
Married
Single
Widow
Divorce
Other
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How many children do you have?
How old are they ?
Who does most of the cooking at home?
On average how many hours do you sleep per night?
Cardiovascular Function
Have you had any of the following condition?
Arrhythmia (NPA)
Blood Clot (NPA)
Coronary Artery Disease (NPA)
Heart Valve Problem (NPA)
Heart attack (NPC)
Heart Valve replacement
Hyperlipidemia (Hight cholestrol)
Hyperkalemia ( High potassium) (NPA)
Hypokalemia (Low potassium) (NPA)
Hypertension (High blood pressure) (NPA)
Pulmonary Embolism (NPA)
Stroke or transient ischemic attack ((NPA)
Congestive heart failure (NPC)
History of congestive heart failure
Current Congestive heart failure (NPC)
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Have you ever had any type of heart surgery ?
Yes
No
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Which Type ?
Other Conditions?
Please give all dates of occurrence
Kidney Function
Have You had any following condition
Kidney Disease (NPA)
Kidney Transplant (NPA)
Kidney Stones
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Do you currently have gout?
YES
NO
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Since when have you had gout?
What medicine has been prescribed?
Have you ever had gout?
YES
No
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When did you start having gout?
Please give dates of events?
Liver Conditions
Have you had any liver conditions ?
Yes
No
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When did you start having liver conditions?
Have you ever had a gallstone incident?
Yes
No
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Colon Function
Do you have any of the following conditions?
Constipation
Crohn's Disease
Diarrhea
Diverticulitis
Irritable Bowel Syndrome
Ulcerative colitis
None of the above
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If Yes, any of these conditions, please give dates of events. For multiple events, please specify:
Neurological Function
Do you have any of the following conditions?
Alzheimer's Disease
Anorexia (history of)
Anxiety
Bipolar Disorder
Bulimia (history)
Depression
Epilepsy (NPA)
Panic attack
Parkinson's Disease
Schizoprenia
No elements found. Consider changing the search query.
List is empty.
Other issues:
Inflammatory Disease
Do you have any of the following conditions?
Chronic Fatigue Syndrome
Fibromyalgia
Lupus
Migraines
Multiple Sclerosis
Osteoarthritis
Psoriasis
Rheumatoid
Other autoimmune or inflammatory Condition
No
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Cancer
Do you have cancer?
Yes
No
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What type of cancer and where is it located ?
Have you had cancer ?
Yes
No
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What type and where is it located ?
Is your Cancer in remission ? (NPC)
Yes
No
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How long have you been in remission?
Diabetes
Do you have diabetes?
Yes
No
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List is empty.
Which type of diabetes?
Insulin-dependent (Insulin injections only)
Non-Insulin-dependent (Diabetic pills)
Insulin-dependent (Diabetic pills and Insulin)
Is your blood sugar level monitored?
Yes
No
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How often is it monitored?
By whom?
Myself
Physician
Do you tend to be hypoglycemic?
Yes
No
Digestive Function
Do you have any of the following conditions?
Acid reflux
Celiac disease
Gastric ulcer (NPA)
Gluten intolerance
Heartburn
History of Bariatric surgery (NPA)
What type of bariatric surgery ?
Ovarian/Breast Function
Do you currently any of the following conditions?
Amenorrhea
Fibrocystic Breasts
Heavy periods
Hysterectomy
Irregular periods
Menopause
Painful periods
Uterine Fibroma
None of the above
Date of last menstrual cycle?
Are you taking oral contraceptive pills?
Yes
No
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Endocrine Function
Do you have thyroid problems?
Yes
No
Please specify your thyroid problems:
Do you have parathyroid problems?
Yes
No
Please specify your parathyroid problems:
Do you have adrenal problems?
Yes
No
Please specify your adrenal gland problems:
Have you been told you have metabolic syndrome?
Yes
No
Do you any other health problems?
Yes
No
Please specify your health problems:
Who is your primary care physician (family doctor)?
Doctor's name:
Specialty:
Patient since:
Last visit:
Please list all the prescriptions medications and supplements you are currently taking
Medications and Supplments