Brief History Form

What is your height?

What is your weight?

If you want to lose weight, how much do you want to lose?

Please list any medical problems:

Are you under the care of another physician for any medical condition?

YesNo

If yes, what for?

Please list any prior surgeries:

Medications

Supplements

Are you having any GI symptoms-bloating, gas, indigestion? If so, please detail

Please place an X if you have ever had any of these conditions

Migraines headachesHeart troubleHigh blood pressureAsthmaHepatitis or liver problemsKidney problemsSeizures or neurological problemsPsychiatricDiabetesThyroid problemsLight-headednessBleeding tendencyBlood clots lungs, legs or bodyArthritis or back troubleExcessive scarring or abnormal healingRecurrent infectionsReactions to anesthesiaEasy bruisingOther

Do you have any drug allergies?

YesNo

If yes, what are you allergic to?

Family Medical History

Do you smoke cigarettes?

YesNo

Do you have any history of cancer?

YesNo

Do you drink alcohol?

YesNo

How much?

Brief Medical History

Reason for visit

General Medical Heath Questions:

Confirmation