Patient Information Sheet for weight loss


Sex:
[radio* radio-343 use_label_element default:1 "Male" "Female"]

How do you prefer to receive appointment confirmations?

Medical History


Are you receiving care from other health care professionals?

Allergies:

Do you or have you ever had any of the following conditions? Check all that apply:

AIDS/HIV

Anemia

Arthritis

Auto Immune Disorder

Asthma

Bleeding Disorder

Blood Disease

Blood Transfusion

Cancer (Chemo/Radiation)

Diabetes

Dizziness

Epilepsy/Seizures

Eczema

Fainting

Hay Fever

Heart Disease

Hepatitis

High Blood Pressure

Infection (active)

Keloid/Hypertrophic Scars

Kidney Disease

Liver Disease

Melanoma

Mental Disorder

Neuromuscular Disorder

Photosensitive Conditions

Pigmentation Disorder

Porphyria

Psoriasis

Respiratory Issues

Skin Disease

Skin Cancer

Sinus Problems

Stomach Problems

Stroke

Thyroid Disease

Other

When did you begin to gain weight?

After an employment change

During a stressful period

After childbirth

After marriage

Other

How long have you been overweight?

What is your cause of your weight problem?

Frequently overeat

Enjoy fatting foods

Lack of activity

Heredity

Other

What is the longest you could stick to a diet?

What other reduction methods have you tried?

Weight watchers

Diet Books

Physician

Do it yourself

Other

Are you under a physician’s care?

Have you been advised by your physician to lose weight?

Do you have any physical problems that you know are associated with your weight?

Why do you want to lose weight?

Appearance

Special Occasion

Health reasons

To please family/friends

Other

Has your significant other encourage you to lose weight?

How important is it for you to lose weight?

Do you work?

Are any of your children overweight?

Do you have sulfa allergy?

I wish to apply for admission to the Allure Aesthetic Center Weight Loss Program. I realize that admission cannot be guaranteed, and will depend on results of a comprehensive medical evaluation I am aware of the financial and time commitments involved, and feel I can complete the program.