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Demographic Information
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First Name
Last Name
Preferred Name
Address
City
State
Zip Code
Phone
Date of Birth
Are you 60 or older? *NOTE* If you are 60 or older, you must bring lab work and EKG dated less than a year ago.
Yes I understand that because I am over 60 I will need to bring in lab work and an EKG dated less than a year ago
No
Patient Age
Gender
Height
Employment Information
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Employer
Occupation
Please tell us how you heard about Scale Solutions
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
Have you ever been diagnosed with an Autoimmue Disease? Check all that apply.
  
NO
Psoriasis
Rheumatoid Arthritis
Lupus
Scleroderma
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
Lumpectomy
Uterine Ablation
Gall Bladder
Augmentation
Gastric Bypass
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?
How long have you smoked?
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:
  • GYN History (Women Only)

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    Last Physical Exam
    Last Menstrual Period
    Menopause
    Yes
    No
    Date of last pap smear
    Any Abnormal Findings?
    Date of Last Mammogram
    What Type of Contraception do you Use?
    Are you currently using hormone replacements?
    What labs have you had done, and what were the results?
  • Lifestyle

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    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?
    How long have you been overweight?
    What do you feel is the reason for your weight problem?
    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?
    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?
    Is your spouse/partner overweight?
    Yes
    No
    Employment status:
    How many children do you have?
    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:
    Activity Level
    Target Weight
    Click on the blue i to read our Informed Consent for Treatment
    I have read and agree to the Informed Consent for Treatment
    Yes I agree.
    Are you the named patient for whom this paperwork applies?
    Yes I am the patient and I am signing the consent for myself.
    No I am not the patient and I am signing the form for them at their request.
    If you are not the patient listed on the form and you have signed their name for them, please write your name here.
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