ealthsmart
WEIGHT LOSS &
GYNECOLOGY

(636) 333-1614

Monday - Thursday
8 am - 5:30 pm

Friday
8 am - 12 pm

Saturday
8 am - 12:30 pm

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First Visit Questionnaire

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Weight Loss Program: Initial Evaluation

Name
First Last
Age
Current Weight
BMI
Weight Goal
Email
Gym Membership
- Yes
- No
IPhone/Kindle/Android/Smart Phone
- Yes
- No
Marital Status
- Married
- Single
Current Medical Problems
Employed
- Yes
- No
Initial evaluation questionnaire
Have you tried to lose weight over past six months and been unsuccessful in achieving your goals?
- Yes
- No
Do you have any of the following?
Hypersensitivity to phentermine or other amphetamines?
- Yes
- No
Family history of diabetes?
- Yes
- No
Do you smoke?
- Yes
- No
Family history of high cholesterol?
- Yes
- No
Advanced arteriosclerosis?
- Yes
- No
Advanced cardiovascular disease?
- Yes
- No
Moderate to severe hypertension?
- Yes
- No
Pulmonary Hypertension?
- Yes
- No
Untreated hyperthyroidism?
- Yes
- No
Have you ever been tested for hypothyroidism?
- Yes
- No
If Yes, Date Tested
MM slash DD slash YYYY
Results
- Normal
- Abnormal
Glaucoma?
- Yes
- No
History of drug abuse?
- Yes
- No
Currently taking any drugs classified as an MAO inhibitor?
- Yes
- No
Do you see a physician regularly?
- Yes
- No
Do you suffer from depression or anxiety?
- Yes
- No
Do you consider yourself an emotional eater?
- Yes
- No
Borderline diabetes?
- Yes
- No
High cholesterol?
- Yes
- No
Are you currently taking any prescribed medications?
- Yes
- No
List of Medications
Name When Taken
What did you eat yesterday for:
Breakfast
Lunch
Dinner
Snacks
Insurance Information
Insurance Company Name
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company Phone
Insurance ID Number
Cardholder Name
First Last
Cardholder DOB