Patient Information Sheet for weight loss Patient Name: Date: Date of Birth: Age: Sex: [radio* radio-343 use_label_element default:1 "Male" "Female"] Address: City: State: Zip: Cell Phone #: Occupation: Email Address: Emergency contact: Name Relationship: Phone #: How do you prefer to receive appointment confirmations? Phone CallText MessageEmail How did you hear about us? Medical History Are you receiving care from other health care professionals? YesNo If yes, please name them and their specialty: Please list any drugs or medications you are taking: Please list any vitamins/herbs/homeopathies/other you are taking: Allergies: Medication Allergies: Cosmetic Allergies: Latex/Other Allergies: Do you or have you ever had any of the following conditions? Check all that apply: AIDS/HIV YesNo Anemia YesNo Arthritis YesNo Auto Immune Disorder YesNo Asthma YesNo Bleeding Disorder YesNo Blood Disease YesNo Blood Transfusion YesNo Cancer (Chemo/Radiation) YesNo Diabetes YesNo Dizziness YesNo Epilepsy/Seizures YesNo Eczema YesNo Fainting YesNo Hay Fever YesNo Heart Disease YesNo Hepatitis YesNo High Blood Pressure YesNo Infection (active) YesNo Keloid/Hypertrophic Scars YesNo Kidney Disease YesNo Liver Disease YesNo Melanoma YesNo Mental Disorder YesNo Neuromuscular Disorder YesNo Photosensitive Conditions YesNo Pigmentation Disorder YesNo Porphyria YesNo Psoriasis YesNo Respiratory Issues YesNo Skin Disease YesNo Skin Cancer YesNo Sinus Problems YesNo Stomach Problems YesNo Stroke YesNo Thyroid Disease YesNo Other YesNo When did you begin to gain weight? After an employment change YesNo During a stressful period YesNo After childbirth YesNo After marriage YesNo Other YesNo How long have you been overweight? year or less2-5 years6-10 years10 years What is your cause of your weight problem? Frequently overeat YesNo Enjoy fatting foods YesNo Lack of activity YesNo Heredity YesNo Other YesNo How many meals you eat daily? How many serious attempts have you made at dieting? What is the longest you could stick to a diet? 0-1 month2-6 months7-12 monthsover 12 months What other reduction methods have you tried? Weight watchers YesNo Diet Books YesNo Physician YesNo Do it yourself YesNo Other YesNo What is the nature of your difficulties while dieting? Are you under a physician’s care? YesNo Have you been advised by your physician to lose weight? YesNo Do you have any physical problems that you know are associated with your weight? YesNo Why do you want to lose weight? Appearance YesNo Special Occasion YesNo Health reasons YesNo To please family/friends YesNo Other YesNo Has your significant other encourage you to lose weight? YesNo How important is it for you to lose weight? Extremely importantVery importantImportantNot very important Do you work? YesNo Full timePart timeOccupation: Number of children: Ages: Are any of your children overweight? YesNo What is your current weight? What was your highest weight in the last 5 years? What was your lowers weight in the last 5 years? What is your goal weight? Do you have sulfa allergy? YesNo What is your goal weight? 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. The above information is accurate to the best of my knowledge.