History Intake

Name: Date of Birth: // Gender:

Address:

Telephone Number: Email Address:

Emergency Contact Name: Telephone number:

Describing My Current Climate

My Most Important Reasons for wanting to Change My Health Climate are:

I decided to come to E-telmed to help me with my weight loss journey because:

I am a stress eater	Yes	No
I eat in the middle of the night	Yes	No
My significant other has a weight issue	Yes	No	N/A

My weight at age 20 was lb.

My Weight one year ago was: lb.

The MOST I ever weighed (non-pregnant) was lb.

I began to gain weight because:

My worst food habit is:

During the last 3 months, I have had episodes of excessive overeating where I ate more than what most people would eat in a similar period of time: Yes No

If "No" go to Beverage box below

If "Yes" complete the following:

During these episodes I feel I have NO CONTROL over my eating	Yes	No
I eat during these episodes even when I am not hungry	Yes	No
During these episodes I feel embarrassed by how much I ate	Yes	No
During these episodes I feel disgusted with myself, or guilty afterward	Yes	No
In the past 3 months, I have sometimes made myself vomit to try to control my weight	Yes	No

BEVERAGE: I drink the following routinely (circle all that apply):

Beverage	Number per Week
Fruit Juice
Sweetened Tea
Sports Drinks
Energy Drinks
Regular Soda
Diet Soda

Typical Meals for me include: (if "none", please note that)

Breakfast	Lunch	Supper	Snacks

I have done the following weight loss programs before:

Program	Year	Result

I have used weight loss medication before: No Yes If yes, which?

I am currently using weight loss products: No Yes If yes, which?

The person(s) closest to me support my intentions to do this program: No Yes Unsure

Long term, I would like to maintain my weight at lbs. (This is my "New Climate" weight)

I would like to be at my "New Climate" weight in months

My Past Health History

My regular doctor is: City and State:

Communication in healthcare is important in order for you to receive the most comprehensive care possible.

At this time my overall health is (circle): Excellent Good Fair Poor

Previous or Current Health Conditions I have had include: (check all that apply to you)

Surgeries I have EVER had include:

Type	Date	Type	Date
1.		4.
2.		5.
3.		6.

Hospitalizations, and/or Serious Injuries I have EVER had include:

Reason	Hospital Name	Date
1.
2.
3.

I am allergic to, or do not tolerate the following medicines:

None (circle if appropriate)	2.
1.	3.

Prescription Medications I CURRENTLY take are:

Medication Name	Dose and Frequency	Medication Name	Dose and Frequency

Over The Counter Medications and/or Supplements/Vitamins I CURRENTLY take are:

Medication Name	Dose and Frequency	Medication Name	Dose and Frequency

My Family's Health History (circle brother or sister as appropriate; check all that apply)

Disease	Father Age: Living: Y N	Mother Age: Living: Y N	Brother/Sister Age: Living: Y N	Brother/Sister Age: Living: Y N	Brother/Sister Age: Living: Y N
Heart Attack/Stroke
Diabetes
Cancer
Psychiatric
Obesity
Other

Symptoms I am experiencing at this time: (check all that apply)

Patient Signature:

Date:

I am...	Married	Never Married	Divorced	Widow/Widower	Other:
# of Children...	0	1	2	3	4 Other:
I live at home with...	Name(s): Age(s):
The town/city I live in is...
For a living I... (occupation)
At this time, my exercise routine includes...	Activity: Minutes: Times/week:
My Current Stress level is...	None	Low	Medium	High
My biggest stressor is...	Job	Relationship	Health	Other:
My tobacco use is...	Current	Former	Never	Quitting
My current alcohol use is...	None	Occasional	Weekly	Daily	A Problem
My current recreational substance use is...	None Type: Frequency:
My current TV/computer time per week is...	Less than 7hrs		7 to 15 hrs		Over 15 hrs
I have had a problem with drug or alcohol addiction in past...	No	Yes Which?