Download Weight Loss Intake Form - Aesthetic Solutions NY

Aesthetic Solutions NY
Aleksandr Benji FNP
98-71 Queens Blvd, Rego Park NY 11374
646-301-4000
Weight Loss Intake Form
Name: ______________________________
Date of Birth ___________
ALLERGIES: (please list any foods, drugs, or medications you are hypersensitive or allergic to. Please include reaction.)
________________________________________________________________________________________________________
Sulfa Allergy_______
Soy Allergy_______
Topical Anesthetic Allergy: _______ Specify_________________
Current Medications (vitamins, birth control pills): __________________________________________
Any mood altering or depression medication: ______________________________________________
1. Skin Assessment:
Do you have any of the following concerns (check ALL that apply):
Fine Lines
Dark Spots
Stretch marks
Deep Wrinkles
Under eye Circles
Sagging Skin
Rough skin texture
Scars (acne or surgical
Large pores
Sagging cheek bones
Other:
None
2. Menstrual/Birthing History
Last Menstrual Cycle
Age of first Menses
# of Abortions
# of Pregnancies
# of Miscarriages
Itching or burning
# Of Days of Menses
Length of Cycle
Irritation or discharge
# of Live Births
Bleeding between periods
Bleeding after intercourse
3. When and where did you last receive health care?
____________________________________________________________________________________
For what reason?
____________________________________________________________________________________
4. Is it possible you may be pregnant? Yes____ No____
If “Yes” How far along are you or may you be?
_____________________________________________________________
5. Do you have any infectious diseases? Yes____ No____ If “Yes” Please Identify:
__________________________________________________________________________________
6. Family History (check those that apply)
Father
Mother
Brother/s
Sister/s
Age (if living)
Health (G=Good. P=Poor)
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Mental Illness
Asthma/Hay Fever/Hives
Kidney Disease
Age (At Death)
Cause Of Death
7. Blood Pressure: What is your most recent blood pressure reading? _____/_____Taken:
___/___/___
HAVE YOU BEEN DIAGNOSED WITH OR HAD ANY OF THE FOLLOWING CONDITIONS:
Please Circle ALL that apply: Past or Present.
Hepatitis
Headaches
Scoliosis
Fatigue
Back Pain
Fever
Insomnia
Heart Murmur
Depression
Hot Flashes
Tendonitis
Rash /skin
problems
Arthritis/Stiff/Painful Sciatica/Shooting Heart Disease
Joints
pain
Cancer
Blood Clots
Gas / Bloating
Chest Pain
Anxiety
Constipation /
Diarrhea
Asthma
Diabetes
Dizziness
Brain Fog
Shoulder Pain
Epilepsy / seizures
Numbness/Tingling
Neck Pain
Leg Pain
Spasms/Cramps
Osteoporosis
Bladder/Kidney Disease
Stroke
High Blood Pressure
Shortness of Breath
Abdominal Pain
Thyroid
Dysfunction
If yes
Explain:__________________________________________________________________________
8. Digestion Issues:
Nausea
Bloating/Gas
Small Round Stool
Vomiting
ABD Distention
Hard Stool
Diarrhea
Constipation
Significant Residual
When Wiping
Blood in stool
Incomplete Evacuation
ABD cramping
9. BM FREQUENCY: Number of times Per Day: 1 2 3 4
If don’t typically have a daily BM how often do you evacuate? 1-2 per week | 3-4 per week | 5-6 per week
| less than once a week
Does it feel like there is more feces stuck in you after having bowel movement? yes / no
Do you have a diet low in fiber: yes / no
Does your diet include a lot of meat/cheese or processed foods: yes / no
Incontinence: yes / no
Pain upon defecation: yes / no
Blood in Stool: yes / no
Hemorrhoids: yes / no
Last Bowel Movement_________________ Previous Interventions: None / Laxatives / Enemas
Other_____
10. Examinations:
Date of last physical examination ______________ Reason: __________________________________
Hospitalizations _________ Dates ____________ Reason: __________________________________
X-Rays: Chest ________Stomach _________ Gallbladder________ Kidney_______ Colon _________
Other _______________________________ Date of last laboratory tests:________________________
Electrocardiogram (heart tracing) ______________ Date of last pap (cancer smear): _______________
11. Weight History:
When did you first become overweight? (Your age then)________________ (year) _________________
How did your weight gain start? Describe any circumstances:
__________________________________ ________________________________________________
___________________________________
What do you think is the cause of your weight problem: _______________________________________
___________________________________________________________________________________
Your present weight: ______________ your weight goal: ___________________height: ____________
What was your highest weight? (excluding pregnancy) _______your age then______ # of years ago:___
What was your lowest weight?________________ your age then__________ # of years ago: ________
Have you ever stayed the same weight for 10 years or more? Yes/ No
Have you attempted to lose weight before? ______ Most lbs lost:_________ how long it took: _________
Describe previous methods of weight loss (e.g. diets, pills, injections, hypnosis, acupuncture) and
describe your results:___________________________________________________________________
___________________________________________________________________________________
Do you currently have any medical concerns? Please List: ____________________________________
____________________________________________________________________________________
12. Energy and Immunity:
Fatigue
Lyme Disease
Slow Wound Healing
Chronic Fatigue
Chronic Infections
Candida / Yeast Infections
Nervousness
Depression
Mental Tension
Grief
13. Emotional/Psychiatric:
Mood Swings
Irritability
14. Head, Eye, Ear, Nose, Throat:
Impaired Vision
Eye Pain/Strain
Impaired Hearing Ear Ringing
Nose Bleeds
Frequent Sore
Throats
Glaucoma
Earaches
Teeth Grinding
Glasses/Contacts
Headaches
TMJ/Jaw Problems
Tearing/Dryness
Sinus Problems
Hay Fever
15. Respiratory:
Pneumonia
Frequent Common Colds
Pleurisy
Asthma
16. Cardiovascular:
Heart Disease
Fluttering
Rheumatic Fever
Difficulty Breathing
Tuberculosis
Chest Pain
Stroke
Varicose Veins
17. Gastrointestinal:
Ulcers
Changes In Appetite
Heartburn
Gallbladder Disease
IBS
Hepatitis A, B or C
Swelling of Ankles
Bruising
Abnormal Bleeding
Nausea/Vomiting
Liver Disease
Abdominal Pain
18. Genito-Urinary Tract:
Kidney Disease
Painful Urination
Kidney
Impaired
Stones
Urination
Frequent UTI
Blood in
Urine
19. Female Reproductive / Breasts:
Irregular Cycles
Breast Lumps/Tenderness
Vaginal Discharge
Premenstrual Problems
Menopausal Symptoms
Clotting
20. Male Reproductive:
Erectile Dysfunction
Prostate Problems
21. Musculoskeletal:
Neck/Shoulder
Muscle Spasms/Cramps
Lower Back Pain
Lower Back Pain
22. Neurologic:
Vertigo/Dizziness
Paralysis
23. Endocrine:
Hypothyroid
Hypoglycemia
Epigastric Pain
Hemorrhoids
Passing Gas
Diverticulitis
Frequent Urination
Heavy Flow
Frequent Urination at Night
Testicular Pain/Swelling
Arm Pain
Leg Pain
Diabetes
Persistent Cough
High BP Palpitations
Heart Murmurs
Pain in Calves
Nipple Discharge
Difficulty Conceiving
Bleeding Between Cycles
Numbness/Tingling
Hyperthyroid
Emphysema
Shortness of Breath
Painful Periods
Heavy Flow
Penile Discharge
Upper Back Pain
Joint Pain
Loss of Balance
Night Sweats
Seizures/Epilepsy
Feeling Hot or Cold
24. Lifestyle:
a. Do you typically eat at least three meals per day? Y/ N If no, why not?__________________________
b. Exercise routine:
______________________________________________________________________
c. Spiritual Practice:
_____________________________________________________________________
d. How many hours per night do you sleep? _____________ Do you wake rested? Y N
e. Level of education completed: High School Bachelors Masters Doctorate Other
f. Occupation: ____________________________________ Employer:
____________________________ Hours/Week: _____________ Do you enjoy work? Y N
Why/Why Not?_______________________________________________________________________
____________________________________________________________________________________
g. Nicotine Use (what form):________________________________ (past or present)
Amount:_______________________________ Frequency:__________________________
h. Alcohol Use (what form):________________________________ (past or present)
Amount:_______________________________ Frequency:__________________________
i. Recreational Drugs (what form):________________________________ (past or present)
Amount:_______________________________ Frequency:__________________________
j. Have you experienced any major traumas? Y N Explain: _________________________
__________________________________________________________________________________
k. How many glasses of non-caffeinated, non-carbonated beverages do you drink per day? _________
l. Interests and Hobbies:
__________________________________________________________________
Have You Been Able To Follow Prescribed Medications/Treatments? Yes/No If “No” why not?
_______________________________________________________________________
I _______________________________________(patient name) acknowledge and understand that:
1) Aleksandr Benji FNP and Aesthetic Solutions NY is NOT my primary Medical Doctor;
2) All medical decisions regarding any current or future health conditions should be addressed by my
primary care physician;
3) Aesthetic Solutions NY serves as only a resource for general wellbeing and preventive medicine and
does NOT treat any existing illness;
4) All supplied information is accurate and forthcoming;
5) I have informed my primary care physician about services I am to receive at Aesthetic Solutions NY
and he/she has no objections to such services.
6) I have not been rushed into making any decisions and I have had ample opportunities to ask Aleksandr
Benji FNP and my primary care physician questions prior to receiving any treatment.
7) I acknowledge that Aleksandr Benji FNP/ Aesthetic Solutions NY does not provide any promises or
guarantees that the treatments I am to received will be effective in helping to improve my current health
conditions and that in coming to Aesthetic Solutions NY. I had previously made a decision independent
of Aesthetic Solutions NY to try the services offered at Aesthetic Solutions NY.
8) I understand that there are NO REFUNDS and that I can afford the services for which I am seeking
and I have not been made any promises as to the results or effectiveness of such services/treatments.
.
_______________________________________
PATIENT SIGNATURE
________________________________________
PRINT NAME
_____________________
DATE