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Demographic Information
Name, Address, Phone, Email
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First Name
Last Name
Preferred Name
Address
City
State
Zip Code
Phone
Date of Birth
Are you 55 or older? *NOTE* If you are 55 or older, you must bring an EKG dated less than a year ago.
o I will need to bring in an EKG dated less than a year ago.
Patient Age
Gender
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Female
Male
Height
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4 ft 0 inches
4 ft 1 inches
4 ft 2 inches
4 ft 3 inches
4 ft 4 inches
4 ft 5 inches
4 ft 6 inches
4 ft 7 inches
4 ft 8 inches
4 ft 9 inches
4 ft 10 inches
4 ft 11 inches
5 ft 0 inches
5 ft 1 inches
5 ft 2 inches
5 ft 3 inches
5 ft 4 inches
5 ft 5 inches
5 ft 6 inches
5 ft 7 inches
5 ft 8 inches
5 ft 9 inches
5 ft 10 inches
5 ft 11 inches
6 ft 0 inches
6 ft 1 inches
6 ft 2 inches
6 ft 3 inches
6 ft 4 inches
6 ft 5 inches
6 ft 6 inches
6 ft 7 inches
6 ft 8 inches
6 ft 9 inches
6 ft 10 inches
6 ft 11 inches
Employment Information
Employment Information
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Employer
Occupation
Please tell us how you heard about Scale Solutions
Medical History
Medical History
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Are you in good health at present?
Yes
No
Are you currently under a doctor's care?
Yes
No
If yes, what for?
Please list your current medications and dosage.
Current Medications:
All
None
Medication List
*List any medications you are allergic to: (if none, enter NKDA)
Allergy Detail
Prescription Appetite Suppressant History
All
None
Yes - please list details-what med-who prescribed-length of use-any problems experienced-number of times used
Only with Scale Solutions-details do not need to be listed
Details of Prescription Diet Meds Used - When, Where, Name of Medicine, How long used, Type of diet followed.
Have you ever been diagnosed with an Autoimmue Disease? Check all that apply.
NO
Psoriasis
Rheumatoid Arthritis
Lupus
Scleroderma
Chron's Disease
Ulcerative Colitis
Non-Specific Connective Tissue Disease
Dermatomyositis
other-see comments
Have you ever been diagnosed or treated for any type of heart condition? Check all that apply.
NO
Angina or Chest Pains
Palpitations
Atrial Fibrillation
Mitral Valve Prolapse
Abnormal Rythme
Heart Valve Disorder
Coronary Artery or Heart Disease
Other - see comments
Have you ever had any surgeries? Please mark or list any major surgery that you have had. Check all that apply.
NO
Appendectomy
Hysterectomy
Tummy Tuck
Liposuction
Other Plastic Surgery
Mastectomy
Lumpectomy
Uterine Ablation
D&C
Gall Bladder
Augmentation
Gastric Bypass
Gastric Band
Orthopedic
Exploratory
C Section
Neurologic
Tubal Ligation
Bladder Surgery
Other - See Comments
Have you ever been diagnosed or treated with a chronic Medical Condition? Check all that apply.
All
NO
polio
drug abuse
cancer-see comments
arthritis (wear and tear)
high blood pressure
diabetes
high cholesterol
high triglycerides
elevated liver enzymes
liver disease
osteoporosis
scarlet
gout
rheumatic fever
ulcers
eating disorder
anemia
thyroid disease
heart disease
depression
bi-polar
anxiety
psychosis
migraine headaches
blood transfusion
alcohol abuse
kidney problems
lung disease
Other - see comments
Medical History Comments
Please list name, age and cause of death of any close family members who are deceased.
Has any blood relative had any of the following:
Glaucoma
Asthma
Epilepsy
High Blood Pressure
Kidney Disease
Diabetes
Psychiatric Disorder
Heart Disease or Stroke
Do you smoke?
Yes
No
How long has it been since you quit smoking?
...Select
I never smoked
I still smoke
less than 1 year
1-2 years
2-3 years
3-4 years
4-5 years
5-6 years
6-7 years
7-8 years
8-9 years
9-19 years
10-15 years
15-20 years
over 20 years
How long have you smoked?
...Select
Never smoked
less than 1 year
1-2 years
2-3 years
3-4 years
4-5 years
5-6 years
6-7 years
7-8 years
8-9 years
9-19 years
10-15 years
15-20 years
over 20 years
How much do you currently smoke? EX: If you smoke 1 cig per day you would mark both "Cigs per day" and "1"
I never have or currently do not smoke
Pipe
Cigars
Cigs per day
Packs per day
Packs per week
One-fourth
One-third
One-half
Three-fourths
Socially-avg=less than 1 cig per day
1
2
1-3
Other - see comments below
What is the maximum amount that you have ever smoked consistently?
I have never smoked
The same as I currently smoke
Pipe
Cigars
Cigs per day
Packs per day
Packs per week
One-fourth
One-third
One-half
Three-fourths
Socially-avg=less than 1 cig per day
1
2
1-3
Other - see comments below
Smoking history comments
Describe improvements you would like to see in your health:
Lifestyle
Lifestyle
Click for instructions
Lifestyle Evaluation
Lifestyle Evaluation
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Present weight:
Goal Weight
When would you like to reach your target weight?
Weight at 20 yrs old:
Weight 1 yr ago:
Maximum Adult Weight
When did you begin to gain weight?
...Select
After childbirth
After marriage
After employment change
During stressful time
Other
How long have you been overweight?
...Select
1 year or less
2-5 years
6-10 years
>10 years
What do you feel is the reason for your weight problem?
...Select
Frequent overeating
Fattening foods
Lack of exercise
Heredity
Other
How many meals do you eat per day?
How many serious attempts have you made at dieting?
What is the longest you have been able to stick to a diet?
...Select
0-1 month
2-6 months
7-12 months
over 12 months
What other weight loss plans have you tried?_2
All
Weight Watchers
Low Carb
Prescription Medication
Exercise Only
Other
Has your spouse/partner encouraged you to lose weight?
Yes
No
A
Explain:
How important is it to you to lose weight?
...Select
Extremely important
Important
Not that important
Is your spouse/partner overweight?
Yes
No
Employment status:
...Select
Full time
Part time
Do not work outside the home
How many children do you have?
...Select
0
1
2
3
4
5
6
7
List their ages:
Are any of your children overweight?
Yes
No
Please list any food allergies:
Your highest weight in the last 5 years:
Lowest:
How many times do you eat out per week?
Frequent restaurants:
How many times do you eat fast food per week?
Who plans & prepares meals:
Who does the grocery shopping?
Do you use a list?
Yes
No
What day/time do you grocery shop?
Food dislikes:
Any specific time you crave food?
Are there any foods you crave or struggle with?
All
No
I eat healty - just to much
Portion size
Chips
Sweets
Chocolate
Baked Goods
Carbs-breads-pasta-rice
Richly prepared foods
Beverages-like Coke-sweet tea-etc.
Other
What is the main beverage you drink? Check all that apply.
Sweet Tea
Unsweet Tea
Water
Diet Soda
Regular Soda
Fruit Juice
Milk
Crystal Light or other sugar-free flavored drink
Vitamin water
Gatoraide-Poweraide
Coffee
Kool aide
Coffee
Other
Other Beverage
Do you drink coffee or tea?
Yes
No
How much daily?
If you drink sodas, what kind?
How much daily?
If you drink alcohol, what kind?
How much daily?
Do you use sugar substitutes?
Yes
No
Do you use butter substitutes?
Yes
No
Do you wake up hungry at night?
Yes
No
Do you tend to eat more under stress?
Yes
No
Are you currently under stress?
Yes
No
Your worst food habits:
Your snack habits:
Your typical breakfast:
Your typical lunch:
Your typical dinner:
Your typical energy level:
...Select
Low
Normal
High
Activity Level
...Select
Sedentary
Light
Moderate
Very Active
Extra Active
Target Weight
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