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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Weight loss Profile Dietary consultation involves a weight loss profile. Its purpose is not to establish a diagnosis, but rather to determine a patient’s health status in order to guide his or her weight-loss plan. A patient may be advised to seek medical advice based on his or her weight loss profile. General Name ___________________________________ Age: ___________ DOB_________ How did you hear about our program? ______________________________________ Job/Occupation:________________________ Who is your doctor? ___________________ Email Address_____________________________________ Do you have any of the following: ____ High blood pressure ____ Heart disease ____ High cholesterol ____ Thyroid disease ____ Low Energy ____ Anxiety/Stress ____ Prostate problems ____ Yeast Infections ____ Kidney stones ____Ulcer ____Glaucoma ____ Kidney disease ____ Lactose intolerance ____ Celiac disease ____ Colon problems ____ Constipation ____ Diverticulosis ____ Cramps (PMS) ____ Food Cravings ____ Sleep Apnea ____TIA’s (ministrokes) ____ Liver disease ____ Illicit Drug Use ____ Gout ____ Acid reflux ____ Trouble sleeping ____ Joint problems/aches ____ Bloating ____ Eating Disorders (Bulimia/ Anorexia) ____ Juvenile Diabetes/ Pre-Diabetes/ Diabetes ____Depression ____Pacemaker/ Defibrillator Please list any other medical problems you have: _______________________________ ____________________________ _______________________________ ____________________________ Are you pregnant? ____ Yes ____ No Do you smoke? ____ No ____ Yes (How much, and how often?________________________) Do you drink alcohol? ____ No ____ Yes (How much, and how often? _________________ _________________) Do you take a multivitamin? ____Yes ____ Do you take Fish Oil? ___ Yes ___No Do you take any medications (including prescriptions, over-the-counter, vitamins)? __________________________________ _________________________________ __________________________________ _________________________________ Are you allergic to any medicines or foods? ________________________________________ _______________________ ________________________ ____________________________ Have you ever had your metabolism tested? ____No ____Yes (By who?________________) Do you exercise? ____ Yes ____ No -If yes, how many days/week_______ Minutes each day_________, and what is your exercise of choice____________________________________________? What is your goal: ____ Weight loss ____ Muscle size ____ Fitness ____ Flexibility ___ Health Please name your 2 favorite foods: __________________________________________ __________________________________________ What types of food do you usually crave? ________________________ ________________________ Do you think that eating food gives you a lot of pleasure? ____ Yes ____ No Do you look for food when you are sad or stressed? ____ Yes ____ No ____ Sometimes Do you ever find yourself eating after you feel full/satisfied? ____Always ____Often ____ Rarely ____ Never Have you ever tried to lose weight before? ____ Yes ____ No If yes, please tell us how: ______________________________________________________ If yes, please specify which diet and why you think it didn’t work for you (ex) too complicated, too much cooking involved, etc.): ____________________________________ ____________________________________________________________________________ Have you had bariatric surgery (surgery for weight loss)? ____ Yes ____ No What time do you usually eat: Breakfast: _________ Dinner:_________ Lunch:__________ Snacks:__________ Please give an example of a typical breakfast, lunch, dinner and snack. (Please be specific, ex. 2 slices of toast with butter, 8 oz. O.J., 8 oz. coffee with 2 tablespoons of sugar and cream) A typical breakfast: ________________________________________________________________________ A typical lunch: ________________________________________________________________________ A typical dinner: _________________________________________________________________________ A typical Dessert: (Only if you have dessert after most meals) _______________________________________________________________________ A typical snack: ________________________________________________________________________ Which one is your largest meal of the day? ___________________________________ Which meal(s) do you tend to skip? _________________________________________ Do you dine out, stop for fast food, or pizza? ___No ___Yes How often?__________ Do you want us to send progress reports to your doctor? ____ Yes ____ No What is your current weight?___________lbs. What was your highest weight?__________lbs. What is your goal weight? ______________lbs. When did you begin to gain weight?_______________________________________________ How long have you been overweight?______________________________________________ Please tell us the main reason(s) why you want to lose weight: _________________________ Any additional information you would like for us to know? _____________________________________________________________________________________ No potential dieter is to be placed on a high protein protocol with a history of or current diagnosis of the any following conditions without written consent from his/her primary care provider or specialist monitoring this patient. History of cardio-vascular events: (i.e. heart attack, stroke, aneurysm, by-pass, stent surgery, history of having cardiac arrhythmia including having a pace-maker) History of or current active cancer, including skin cancers Pregnant female (note from OB/GYN ONLY) Breast feeding female Severe Liver Disease Severe Kidney Disease Diagnosis or history of congestive heart failure (CHF) Patients currently on Lithium therapy Patients with a diagnosis of Parkinson’s Disease I agree to consult with my primary care physician to guarantee the safety of the recommendations made to me for weight management and exercise. ________________________________ Patient Reviewed by Physician __________________________________ Witness