|Medical History Form
Name: Age: Sex: M F
Family Physician: Phone:
Past Medical History: (check all that apply)
Polio Measles Tonsillitis
Jaundice Mumps Pleurisy
Kidneys Scarlet Fever Liver Disease
Lung Disease ` Whooping Cough Chicken Pox
Rheumatic Fever Bleeding Disorder Nervous Breakdown
Ulcers Gout Thyroid Disease
Anemia Heart Valve Disorder Heart Disease
Tuberculosis Gallbladder Disorder Psychiatric Illness
Drug Abuse Eating Disorder Alcohol Abuse
Pneumonia Malaria Typhoid Fever
Cholera Cancer Blood Transfusion
Arthritis Osteoporosis Other:
1. History of High Blood Pressure? Yes No
2. History of Diabetes? Yes No
At what age:
3. History of Heart Attack or Chest Pain? Yes No
4. History of Swelling Feet Yes No
5. History of Frequent Headaches? Yes No
Migraines? Yes No Medications for Headaches:
6. History of Constipation (difficulty in bowel movements)? Yes No
7. History of Glaucoma? Yes No
8. Gynecologic History:
Pregnancies: Number: Dates:
Natural Delivery or C-Section (specify):
9. Any Surgery: Yes No
10. Are you taking any medications at the present time? Yes No
11. Any allergies to any medications? Yes No
12. Smoking Habits: (answer only one)
You have never smoked cigarettes, cigars or a pipe.
You quit smoking years ago and have not smoked since.
You have quit smoking cigarettes at least one year ago and now smoke cigars or a pipe without
You smoke 20 cigarettes per day (1 pack).
You smoke 30 cigarettes per day (1-1/2 packs).
You smoke 40 cigarettes per day (2 packs).
13. Do you drink alcohol? Yes No
What?________________________ How much?_______________________
14. Do you drink cola drinks with caffeine? Yes How much daily?________________________
15. Do you use street drugs? Yes No How often?_________________________
16. Activity Level: (answer only one)
Inactive¾no regular physical activity with a sit-down job.
Light activity¾no organized physical activity during leisure time.
Moderate activity¾occasionally involved in activities such as weekend golf, tennis, jogging,
swimming or cycling.
Heavy activity¾consistent lifting, stair climbing, heavy construction, etc., or regular participation
in jogging, swimming, cycling or active sports at least three times per week..
Vigorous activity¾participation in extensive physical exercise for at least 60 minutes per session
4 times per week.
17. On a scale of 1 to 5 (1=least satisfied 5=very satisfied), rate the following situations in your life.
Married Life 1 2 3 4 5 N/A
Present Job 1 2 3 4 5
Overall satisfaction with self 1 2 3 4 5
Hours of TV daily Never_______ Rarely_______ 3-5 Hrs_______ 5+ Hrs_______
Substitute eating as an emotional outlet Yes No
Number of pregnancies _______
Number of children _______
Number of miscarriages or abortions _______
18. Behavior style: (answer only one)
You are always calm and easygoing.
You are usually calm and easygoing.
You are sometimes calm with frequent impatience.
You are seldom calm and persistently driving for advancement.
You are never calm and have overwhelming ambition.
You are hard-driven and can never relax.
19. Advanced directive/living will? Yes No
20. Family History:
Age Health Disease Cause of Death Overweight?
Has any blood relative ever had any of the following:
Glaucoma: Yes No Who: Asthma: Yes No Who:
Epilepsy: Yes No Who:
High Blood Pressure Yes No Who:
Kidney Disease: Yes No Who:
Diabetes: Yes No Who:
Tuberculosis: Yes No Who:
Psychiatric Disorder Yes No Who:
Heart Disease/Stroke Yes No Who:
Adopted Yes No
I have been overweight since age _______
Number of years at current weight?_______
What has been your maximum lifetime weight (non-pregnant) and when?
Most weight lost on a single diet?____________________________
Is your spouse, fiancée or partner overweight? Yes No
By how much is he or she overweight?______________________________
How often do you eat out?_____________________________________
What restaurants do you frequent?__________________________________________
How often do you eat “fast foods”?______________________________________
10. Who plans meals? Cooks? Shops?
11. Do you use a shopping list? Yes No
12. Food dislikes:
13. Food you crave:
Do you use a sugar substitute? Yes No
Do you use butter _______ margarine _______
Do you awaken hungry during the night? Yes No
17. What are your worst food habits?
18. Snack Habits:
What? How much? When?
19. When you are under a stressful situation at work or family related, do you tend to eat more? Explain:
20. Do you think you are currently undergoing a stressful situation or an emotional upset? Explain:
21. Typical Breakfast Typical Lunch Typical Dinner
Time eaten: Time eaten: Time eaten:
Where: Where: Where:
With whom: With whom: With whom:
Reasons for eating? Physical hunger_______ Loneliness _______ Anxiousness _______
Happy _______ Bored _______ Angry _______ Tired _______
22. Weight control attempts? Bingeing and purging _______ Bingeing and food restriction _______
Diuretics _______ Laxatives _______ Vomiting _______
23. Reasons for being overweight? Inactivity_______ Emotional well-being_______
24. Previous diets you have followed: Give dates and results of your weight loss:
25. Food Intolerance? Lactose_______ Gluten_______ Other____________
This information will assist us in assessing your particular problem areas and establishing your medical management. Thank you for your time and patience in completing this form.