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Medical & Diet History Form

Identification Information

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1. Diet History

Were you overweight as a child?:

Name of Diet Approx. Date # lbs. Lost/Regained

2. Medical History
Do you or have you ever experienced any of the following conditions?
Asthma or Chronic Bronchitis: 
Back Pain: 
Bladder Incontinence: 
Blood Clots (due to injury or surgery): 

Cardiac Problems (palpitations, pain, heaviness in chest): 

Chemical Dependency: 
Elevated Cholesterol or Triglycerides: 
Circulatory Problems (swelling, tingling, numbness): 

Crohn Disease: 
Frequent Headaches: 
Heart Attack: 
Hepatitis B or C: 
High Blood Pressure: 
Home Oxygen Therapy: 
Irritable Bowel Syndrome: 
Pain in Weight Bearing Joints: 

Kidney Dialysis: 
Irregular or Painful Menses: 
Reflux (heartburn, indigestion)(physician diagnosed): 
Shortness of Breath upon Exertion: 
Skin Conditions (Psoriasis, Yeast, Boils, Eczema): 
Sleep Apnea (c pap or bi pap): 

3. Medications
Current Medications
Medication Name Dosage Condition Being Treated

Are you allergic to any medications?
Medication Name Reaction
4. Significant Family History
List any family members who have suffered or experienced any of the following conditions. In addition to listing the person’s relationship to you, please also list if they are maternal (Mom’s family) or paternal (Dad’s family).
5. Surgeries & Hospital Admissions
Date Reason
6. General History
Do you smoke?:
Do you drink alcohol?:
Do you use drugs?:
Do you use contraception?:

7. Physical

8. Primary Care Physician