PATIENT WEIGHT LOSS QUESTIONNAIRE

Name:

DOB:

Phone:

Address:

Occupation:

Review of Current Medications:

Med Allergies:

Height:

Weight:

BP:

Pulse

BMI:

Target Weight:

History of Present Illness

Previous prescription weight loss medication:

How much weight have you gained in the past two years?

Weight issues as a child?

Yes No

Past Medical History

PCOS

Diabetes

HTN

Hypercholesterolemia

Childhood Obesity

Family History

Obesity

Heart Disease

Diabetes

PCOS

Past Surgical History

Gastric Bypass

Gastric Band

Other non-Orthopedic Surgeries (list below)

If Other non-Orthopedic Surgeries, list below

Contraindications

Hx of any Thyroid Cancer

Hx of Multiple Neoplasia 1 or 2

Hx Pancreatitis

Current or Planned Pregnancy

Exercise Level

Sedentary

Moderate

Active

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Patient Signature:

Date: