MediTrim - Grand Junction`s HCG Weight Loss Clinic

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Patient Intake Form
(LasQ
Girsfl
Patient Name:
Patient Address:
Ctty:
Home
(MD
zip,;
State:
Phone:
Beeper/Cellular:
Birthdde:
Sex:
Age:
M
F
E mail:
County of Parents' Birth:
County of Birth:
Emnlovment Information:
Occupation:
Patient Employer:
Employer Ad&ess:
Crty:
Work phone No:
Social
ztp
Stafe:
Ext.
Securiw:
Drivers License:
In Case of Emergencv:
Name:
Phone:
Phone:
Phone:
Relationship:
Patie,nt's Spouse:
Family Physician:
Referred by:
lYeight llistory
When did you first become overweight? (your age theQ
How did your weight gain start? Describe any circumstances:
,(Year)
What do you think is the cause ofyourweight problem?.
your weight goal:
Your prese,nt weight:
your age
# of years
(excluding
What was your highest weight?
your
# ofyears
age then
What was you lowest
Have you ever stayed the same weight for 10 years or more? Yes:/ No
how long it
most lbs
Have you attempted to lose weight
Describe previous methods of weight loss (e.g. diets, pills, injections, hypnosis, acupuncture) and describe your
weight?
pregnmcy)
lost:
before?
results:
Where and when do you do most ofyour overeating?
Please make any c,omme'rts that you think might be
helpful:
then
ago:ago:took:-
Do you currently have any medical concems? Please List:
Past I{istory: (Please check if you have had any of the following):
E Allergies, T5pe:
tr Birth defects or abnorrnalities
E Exposed to tuberculosis
E Mumps
E Fever German Measles (3 day)
E Frequent Colds
E Pnetrmonia fr Diabetes: Tlpe:
E Cancer, Type:
tr Scarlatina
E Measles
tr Diphtheria
E Rheumatic
fl Whooping Cough
E Polio
E Chickenpox fl Tonsillitis
fl
E Influenza
E
Scarlet Fevq
Other Diseases
EI Operations :( dates)
Current Medications (vitamins, birth control pills):
Any mood altering or depression medication:
Allergies to medicines, foods,
Family llistory:
Father:Health
Mother:Health
# of siblings:_#
_
_
Age
Age
living_
Deceased at age _Cause
Deceased at age Cause
#deceased:
_Cause
Family Diseases: Check diseases known in your blood relatives (not yourself)
tr High bloodpressure
tr Migraine
E Strokes
tr Kidney disease
E Arthritis
E Other
Heartfiouble
Dropsy
Diabetes
tI Syphilis or (bad btood) tr Suicide
E Rheumatic
fl Fever
E Allergy
E
(abnormal)
tr Bleeding
tr
E Cmcer
E
Examinations:
Date of last physical oxamin4fiel
Hospitalizations _
Dates
X-Rays: Chest_Stomach
Other
\Electrocrdios{n
(heart racing)
-
E Anemia
tr
Epilepsy
E
Nervous breakdown
tr
Obesity
Reason:
Reason:
Gallbladder
Kidney
Colon
Date of last laboratory tests:
Date of last pap (cancer smear):
Do you now have or have had any of the following?
tr Itching E Eczema
tr Arthritis El Limitation ofmotion
tr Pain or stiffrtess (nec$
E Asthma tr Lung disease
E
Heart
trouble
E Hives
E Backache
E Goiter
E Raise sputum
E Jointpains
E Muscle aches
pains
tr Leg
E Heel Pains
E Swelling, enlarged glands
E Emphysema Bronchitis
tr High blood pressure EI Shorhress of breath tr Palpitation or fluttering
pain tr Lips or nails turn blue
E Indigestion E Nausea or vomiting tr Abdominal
fl
Chest
tr Hardbowel mov€ments
pain
No. ofbowel move,ments - daily
D Tire easily
fl
E
tr Diarrhea
E Colitis
Gas or
bloating
Swelling of ankles
E Jaundice E Hemorrhoids (piles)
tr Urinary System
tr Painftlurination
tr Dribbling of urine
E Trouble sleeping
tr Fainting
tr Neuritis or Neuralgia
fl Hernia
tr Bleeding or black stools
tr Kidney disease tr BladdEr disease tr Kidney
fl Pus or blood in urine tr Albumen or sugar in urine
E Vaicose veins I
E Headaches E
E Convulsions E
stones
Nervousness or anxiety
Bored or depressed E Nervous breakdown
E Loss of consciousness
Numbness
El Paralysis
Menstrual History:
Z8daycycle? Ifno,howmanydays?
*age:
Pain with periods?
ofbleeding:
flow: Light_Med.
menstrual period:
Date of Ist day of last:
periods:
Bleeding after intercourse:Bleerling between
Itching or burning
lrritation or discharge:
Me,nstruationbegan
Duration
Amount of
Are you on birttr control? (method):
-Heavy
B- Complex iniections:
tr One injection
per week
E Two injections per week
tr
Three injections per week
Statements on this patient inake form are accurate and true to the best of my lnowledge. I understand that
treatnents will be based on the information provided herein. If I willingly withhold knowledge from my treating
physician, I accept full liability from any consequences 6ising there from.
All
I have read md understand all of the above and have agreed to these terms.
Pdient's Name and Signature
Date
I reviewed the patient's medical history and approve the following treatment:
HCG
B- Complex
days
injections
ml
Nurse Practitioner's Name and Signature
per week
Date