For A Thin You
PATIENT MEDICAL HISTORY
Today's Date:
Patient's Last Name:	First:	Middle:	Preferred Name:
Date of Birth:	Age: Sex:	Marital Status:	Social Security # (opt)
Street Address:		City and State:		Zip Code:
Home Phone:	Cell Phone:	E-mail Address:
Occupation:	Job Title:	How Long:	Work Phone:
Employer:	Employer's Address:
Spouse's Name:	Spouse's Employer:		Spouse's Work Phone:
Relative other than at your home address:		Relationship:	Phone Number:
Children's Names and Ages:			How did you hear about us?
PATIENT HISTORY check all that apply)
General	Head/Ears/Nose/Throat		Pulmonary
□ Unplanned Weight Change	□ Visual Problems		□ Cough	□ Fall Asleep at Wheel
□ Fevers/Chills	□ Glaucoma		□ Wheezing	□ Asthma
□ Bulimia	□ Hearing Problems		□ Shortness of Breath	□ Never Feel Rested
□ Sweats	□ Sinus Infection		□ Positive TB Test	□ Sleep Study Done
□ Loss of Energy/Fatigue			□ Snoring	□ Results:___________
□ Anorexia Nervosa			□ Headache upon Waking	□ Insomnia
□ Other (name)
Please list ALL prescriptions and over-the-counter medications presently using:
Please list ALL prior surgeries and dates:
Please list ALL allergies:
Do you exercise?	What kind?		How much?
Do you: □ eat breakfast? □ eat lunch? □ eat dinner?		□ eat between meals?	□ eat at night?	□ eat when stressed?
Do you take: □ vitamins? □ laxatives? □ hormones?		□ pain medication?	□ stomach medication:	□ birth control pills?
□ nerve medication?	□ cold medication?	□ herbal supplements? (name)
Do you smoke? How much? Do you use caffeine? How much?			Do you drink alcohol?	How much?
In the past year, have there been any changes in your family? (check all that apply)
□ Marriage □ Separation	□ Divorce □ Loss of Job □ Birth □ Serious Illness □ Death			□ Other
PATIENT'S SIGNATURE		PHYSICIANS SIGNATURE
Your signature indicates that the above information is complete and true. Physician will sign after reviewing with patient Revised 6/14/07