Download to our Medical History Form!

CONFIDENTIAL MEDICAL HISTORY
The following information is necessary for our counselors to determine your eligibility for the program and establish your needs
during the weight loss period. Please answer all questions accurately to the best of your knowledge.
All information will be kept confidential according to HIPAA guidelines. Thank you.
I.
PERSONAL INFORMATION
DATE: ________________________
Name: _________________________________Email: ____________________________Home Phone: _______________________________
Address: _________________________________________________________________Cell Phone: _________________________________
Cell Provider
City: _________________________________State:_____________________ZIP:____________ Age: ________Birthdate: ____________
Employer: ___________________________________________________________Occupation: _____________________________________
Spouse/Partner Name: ___________________________ Employer: __________________________Occupation:_______________________
HAVE YOU BEEN TO AGELESS BEFORE? Yes____ No____ If yes, when? __________________________________________
HOW DID YOU HEAR ABOUT AGELESS?
PLEASE CHECK ONE:
BE SPECIFIC

Physician Referral
Name: ________________________________________________ Phone #: ______________________________
Practice Name: ________________________________________________ Location: _____________________________
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Patient Referral
Name: _______________________________________________________
TV Station
Name: _______________________________________________________
Radio Station
Name: _______________________________________________________
Print
Name: _______________________________________________________
Social Media
Explain: ______________________________________________________
Event/Health Fair
Explain: ______________________________________________________
Other
Explain: ______________________________________________________
II.
MEDICAL HISTORY
1.
Primary Care Physician: ____________________________________________ Date of Last Examination: ____________________________
Practice Name: __________________________________________ Location: ___________________________ Phone: __________________
2.
Please List ALL Medications You Are Currently Taking (Including Birth Control Pills, Aspirin, Laxatives, Vitamins, Etc.)
Please Include Dosage, Strength, And Frequency:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
3.
Have You Ever Taken ANY Of The Following? Steroids: Yes____ No____
Appetite Suppressants: Yes____ No____
Chemotherapy: Yes____ No____
4.
Known Medication Allergies: ___________________________________________________________________________________________
5.
Other Allergies: ______________________________________________________________________________________________________
6.
Are You Currently Under A Physician’s Care For Any Medical Condition Requiring Treatment? Yes____ No____
If Yes, Please Describe: ________________________________________________________________________________________________
____________________________________________________________________________________________________________________
7.
Fertility Drugs: Yes____ No____
Hormone Replacement Medication: Yes____ No____
If You Have Had Recent Surgery, Explain: ________________________________________________________________________________
____________________________________________________________________________________________________________________
101 Prosperous Place Ste 150
AgelessCenter.net
10003 Forest Green Blvd
Lexington, KY 40509
Louisville, KY 40223
859.335.1330
March 2015
502.896.0060
8.
What Other Surgeries Have You Had? (List Year) __________________________________________________________________________
____________________________________________________________________________________________________________________
9.
List Reasons (And Year) For Any Other Hospitalizations Or Major Illnesses: ___________________________________________________
____________________________________________________________________________________________________________________
10.
Are You Now Pregnant Or Breast Feeding?
11.
Are You Currently On Any Specific Diet Prescribed or Recommended By Your Physician Or A Dietitian? Yes____ No____
Explain:_____________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
12.
Do You Use Tobacco Products? Yes____ No____ If So, What Type/How Often? ________________________________________________
13.
Do You Drink Alcohol? Yes____ No____ If So, What Type/How Often? ________________________________________________________
14.
Do You Take/Use Recreational Drugs? Yes____ No____ If So, What Type/How Often? __________________________________________
III.
PLEASE CHECK IF YOU HAVE HAD OR BEEN TREATED FOR ANY OF THE FOLLOWING. (If Yes, Please Explain):
GASTROINTESTINAL
____GERD
(gastro esophageal reflux disease)
____IBS
(irritable bowel syndrome)
____Celiac
____gluten sensitivity
____heartburn
____ulcerative colitis
____Crohn’s disease
____diverticulitis/osis
____dumping syndrome
____gastric bypass
____gastric banding
____gastric sleeve
____other bariatric surgery
____diarrhea
____constipation
____other
Yes____ No____
KIDNEY
____poor kidney function
____kidney stones
____kidney failure
____nephritis
____kidney/bladder infections
____other
REPRODUCTIVE SYSTEM
____fertility treatment
____premenstrual syndrome
____PCOS
(polycystic ovarian syndrome)
____hysterectomy
partial
total
____hormone replacement therapy
____BPH
(benign prostatic hypertrophy)
____other
RESPIRATORY SYSTEM
____asthma
____COPD
ENDOCRINE & HEMATOLOGY
____anemia
____anti-coagulant therapy
____emphysema
____chronic allergy/sinus problems
____other
____diabetes mellitus type I
____diabetes mellitus type II
____ insulin dependent?
____hypoglycemia
____hypothyroid
____hyperthyroid
____gout
____metabolic syndrome
____growth problem
(chronic obstructive pulmonary disease)
LIVER AND GALL BLADDER
____hepatitis A /B/ C
____elevated liver enzymes
____cirrhosis
____jaundice
____gall bladder disease
____gall stones
____other
IV.
WEIGHT LOSS HISTORY
(blood thinners)
Explain: ____________________________________________________
CARDIOVASCULAR
____arrhythmia
____hypertension
(high blood pressure)
____irregular pulse
____hypertension
____poor circulation
____CABG
(coronary artery bypass graft)
____MI
(myocardial infarction/heart attack)
____stents/angioplasty
____pacemaker/defibrillator
____atherosclerosis
____coronary artery disease
____other
GENERAL
____cancer
surgery chemo radiation
____fluid retention
____arthritis
osteo rheumatoid psoriatic
____fatigue
____AIDS
____lupus
____fibromyalgia
____eczema
____plantar fasciitis
____recurrent infections
____psoriasis
____joint replacement surgery
____other
PSYCHOSOCIAL
____SAD
(seasonal affective disorder)
____OCD
(obsessive compulsive disorder)
____schizophrenia
____bi-polar disorder
____depression
____anxiety
____anorexia
nervosa bulimia
other
____alcoholism
____drug
dependence addiction
____history of abuse
____difficult home environment
____other
NEUROLOGIC SYSTEM
____epilepsy/seizures
____stroke
____syncope/fainting spells
____neuropathy
____MS
(multiple sclerosis)
____brain injury
____brain or spinal tumor
____other
1.
Current Weight: __________
2.
What You Would Like To Weigh Or What Clothing Size Would You Like To Wear? _______________________________________________
3.
How Long Have You Been Overweight? __________________________________________________________________________________
4.
Has Your Physician Recommended That You Lose Weight? Yes____ No____
101 Prosperous Place Ste 150
Lexington, KY 40509
859.335.1330
AgelessCenter.net
March 2015
10003 Forest Green Blvd
Louisville, KY 40223
502.896.0060
Patient Name: _____________________________________________________________ Date: _____________________________________________
5.
Is Anyone Else In Your Family Overweight? (Spouse, Parents. Etc.) ___________________________________________________________
6.
How Long Have You Been Thinking About Losing Weight? __________________________________________________________________
7.
What Do You Do For Recreation? _______________________________________________________________________________________
8.
Do You Feel That You Have Good Eating Habits? __________________________________________________________________________
9.
Do You Exercise?
10.
Do You Drink Water? Yes____ No____ If So, How Often? ___________________________________________________________________
11.
Are You Having Any Physical Discomfort Associated With Your Weight? ______________________________________________________
____________________________________________________________________________________________________________________
12.
Previous Methods Of Weight Reduction And Results: ______________________________________________________________________
____________________________________________________________________________________________________________________
13.
Is, Or Will Your Spouse/Partner Be Aware That You Are On Our Program?
14.
Why Do You Want To Lose Weight? Check All That Apply:
Yes____ No____ If So, What Type/How Often? ___________________________________________________________
____ Special Event
____ Birthday
____ Anniversary
____ Health
____ Career
____ Social Life
____ Recreation
____ Clothing
Yes____ No____ N/A____
____ Appearance
____ Personal Life
____ Self
____ Other___________________________________________________
15.
What Do You Feel Are Your Primary Challenges/Obstacles In Maintaining A Healthy Lifestyle? ____________________________________
____________________________________________________________________________________________________________________
16.
Would You Describe Yourself As A: Check All That Apply
____Emotional Eater
____Couch Potato
17.
____Boredom Eater
____Stress Eater
____Overweight, But Healthy Habits
Are You Ready To Make The Commitment To Lose Weight?
____Foodie
____Busy Bee (food is a nuisance)
Yes____ No____
I Understand that The Above Information Will Be Kept Confidential And Is Accurate To The Best of My Knowledge:
Client Signature________________________________________________________________________ Date_________________________________
Counselor______________________________________________________________________________ Date_________________________________
Release of Medical Records- If you would like us to send your medical information to your other healthcare providers.
I hereby give authorization for The Ageless Weight Loss and Wellness Center to release all pertinent information regarding my past medical
history, lab results, and any other confidential chart information to:
___________________________________________________________________________________________________________________________
Physician Name or Medical Facility
___________________________________________________________________________________________________________________________
Physician or Medical Facility Address
_____________________________________________________
Client Signature
_____________________________________________________________
Date
Witness Signature
Date
May we contact you by email with informative materials helpful to your weight loss and weight management success, and special sales benefits
of interest to you, our valued client? Your address will be held in strict confidence and never forwarded or sold to any other organization,
required under the Privacy Act.
 YES
 NO
_____________________________________________________________________________________________
Please Print Your E-mail Address Clearly
101 Prosperous Place Ste 150
Lexington, KY 40509
859.335.1330
AgelessCenter.net
March 2015
10003 Forest Green Blvd
Louisville, KY 40223
502.896.0060