Gbp medical history

Education Level Primary School⎔ High School⎔ College⎔University⎔Post Graduate⎔ Occupation ____________________________Employer Email Address REFERRAL INFORMATION
How did you hear about our program? Your Doctor⎔ TV⎔ Radio⎔ Word of Mouth⎔ Press⎔ Internet⎔ (If so, which site) SOCIAL PROFILE/FAMILY STRUCTURE
Married:⎔ Single:⎔ Divorced:⎔ Widowed:⎔ Partnered:⎔Children/Ages WEIGHT HISTORY
Please indicate your weight at the following times. Please indicate whether you consider your weight was below average, average, above average or very heavy in the relevant boxes.
Weight at beginning of high school (10-12 yrs) Weight at end of high school (15-18 years) Weight at time of commencing work (21 years) Weight at time of marriage (if applicable) WEIGHT LOSS HISTORY
Weigh LessWeight WatchersSure SlimMadame/ MonsieurBio SlimHerbal LifeAtkins dietDietician/NutritionistMedically Supervised dietsWeight Loss injectionsHypnosis Jaw wiringFad dietsSelf dietsAppetite SuppressantsCabbage soup dietGrape seed dietBlood group dietTLC Well being ClinicXenical/ReductilAny others: Details of any other weight loss measures (including surgical)
Was there any particular event that lead to significant weight gain
Do you have a family history of any of the following and if so, please indicate: OTHER RELATIVES NO
SIBLING / (cousins, aunts,
ALLERGIES (including foods, medications, latex) Yes⎔ No ⎔
If yes, please give details
There is increasing evidence that alcohol consumption may help some of the risk factors that lead to heart disease and stroke. Indeed it may even decrease the mortality associated with these serious conditions.
We wish to look at these risk factors in people who are obese. To assist us we would like you to answer these few simple questions about your alcohol consumption.
Do you drink any alcohol? Yes⎔ No ⎔ ( If No,go to part B)How often do you have a drink containing alcohol? Every Day⎔Most days⎔Most weeks⎔ Most months⎔Rarely (once or twice a year)⎔What is your preferred alcoholic type beverage you drink? Please mark 1, 2 or 3, in order of preference.
Beer⎔ Wine⎔ Spirits⎔ When do you usually drink? Social occasions ⎔Parties⎔ With meals⎔ Before meals⎔ After Meals⎔ Weekends⎔
If you indicated above that you drank every day, most days or most weeks, please circle how many
standard drinks you would have in a typical week. ( 1 standard drink = 1 small glass of wine, 1 glass of
full strength beer or a shot of liquor).
1-2 ⎔ 3-10⎔ 11-20⎔ 21-40⎔ 40+⎔
Part B- for non-drinkers only.
Is there a reason you don’t drink any alcohol?
Do you smoke? Yes⎔ No⎔ Never⎔ If yes: how many per day? Have you smoked in the past? ⎔Yes ⎔ No If yes, how many per day? For how many years? When did you stop smoking? QUESTIONS FOR THE LADIES
Do you have a regular Menstrual Cycle? (26 - 33 days) Yes⎔ No⎔If No, please describe Do you have problems with excessively heavy Menstrual Cycle? Yes⎔ No⎔If Yes, please describe Have you had difficulty in conceiving in the past? Yes⎔ No⎔ Do you currently have problems with infertility? Yes⎔ No⎔ Have you suffered from excess body hair or acne? Yes⎔ No⎔ Have you every been told by a doctor that you have polycystic ovaries? Yes⎔ No⎔ Have you had problems with pregnancy and/or childbirth? Yes⎔ No⎔ Have you had a caesarean section? Yes⎔ No⎔ SURGICAL HISTORY
Please give details of any past operations:
Have you ever suffered from any of the following health problems:
DiabetesDiabetes while pregnantAsthmaRespiratory/Breathing problemsArthritis or joint painBack painKidney or urinary disorderNeurologicaLPsychological/nervous disorderGallstonesReflux or heartburnGastric or duodenal ulcerHepatitis or liver diseaseHigh blood pressureHeart diseaseHigh cholesterolAnemia or bleeding disorderThrombosis or clotting disorderVaricose veins or leg swellingEczema or skin conditionHayfever or Rhinitis/SinusitisEasy bruising Please give details of any major illnesses /problems
Is there anything else that keeps you awake at night? Yes⎔ No⎔Details Rate the quality of your sleep: Good⎔ Fair⎔ Poor⎔ Is your sleep pattern disturbing your partner? Yes ⎔ No ⎔ N/a⎔ SYMPTOMS OF SLEEP APNEA
To answer each question, mark the horizontal line with a ⏐ in the position that best indicates your answer.
1. How often do you snore? 2. Do you wake during the night with a choking feeling? 3. How often would you sleep more than 8 hours in total in a 24 hour period? 4. How often do you wake up more than once during the night? 5. Do you have a headache when you wake up in the morning? 6. Have you noticed a reduction in your libido or sex drive? 8. Has anyone noticed that you momentarily stop breathing during your sleep? 10. Do you wake up in the morning feeling confused? 11. How often do you have a nap during the day? 13. Have you or anyone else noticed a change in your personality recently? 14. How often do you doze off or fall asleep while driving?
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?
This refers to your usual way of life in recent times. Even if you haven't done some of these things
recently, try to work out how they would have affected you.
Use the following table to choose the most appropriate option for each situation by placing a check in
the boxes below:
Moderate High
of dozing of dozing
of dozing
Sitting, inactive in a public place (e.g. a theatre or a meeting) As a passenger in a car for an hour without a break Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in the traffic EMPLOYMENT
Current Employment:
Are you full-time ⎔ part-time⎔ or volunteer⎔ If you are unemployed, what is the reason? Are you actively looking for work? Yes⎔ No⎔ Has your weight made it difficult to find employment? Yes⎔ No⎔
If employed, please state what level of activity your job involves:
Physically not very active⎔ Moderately active⎔ Very active(labour)⎔ MEDICATIONS
Please indicate whether you are now or have previously taken any of the following medications *If yes, please state the name of the medication and how long you have been or were taking it.
Psychiatric disorderMigraineAssisted Weight LossEpilepsyAsthmaHormonesEstrogenCortisoneBlood Pressure Please list in detail all medications that you have used in the last 12 months. Please include any dietary supplements, cremes, eye drops, etc.
1. Do you take multivitamin tablets or other dietary supplements? Yes⎔ No ⎔ If yes, how often? Rarely⎔ Monthly⎔ Weekly⎔ Most days⎔ Every day⎔Please name the multivitamin or other dietary supplements you usually take : BREATHING HISTORY
Does being at work ever make your chest tight or wheezy? Yes⎔ No⎔Details Have you ever had to change your job because it affected your breathing? Yes⎔ No⎔Details Have you ever worked in a job, which exposed you to vapors, gas dust or fumes? Yes⎔ No⎔Details Have you ever had asthma? Never⎔Yes⎔ No⎔ Currently⎔In the past⎔Don’t know⎔ Have you ever had to spend a night in hospital because of asthma/breathing problems? Yes⎔ No⎔ If yes was it in the last 12 months Yes⎔ No⎔In the last 12 months, have you visited an Emergency Room or seen a doctor urgently because you had asthma or breathing problems? Yes⎔ No⎔ Details In the last 12 months, have you taken a course or prednisone because of asthma or breathing problems? In the last 12 months, have you missed work or school because of asthma or breathing problems? COUGH AND SHORTNESS OF BREATH
Do you usually have a cough? Yes⎔ No⎔ Do you usually bring up phlegm from your chest when you cough? Yes⎔ No⎔ Do you get short of breath on exertion? Yes⎔ No⎔ Do you get short of breath walking? Yes⎔ No⎔ Do you get short of breath walking uphill or doing housework? Yes⎔ No⎔ In the last 12 months, have you had an attack of shortness of breath that came on when you were not exercising and without obvious cause? Yes⎔ No⎔
WHEEZE (a whistling noise that comes from the chest and may cause breathlessness or difficulty in
In the last 12 months, have you had wheezing in your chest? Yes⎔ No⎔ In the last 12 months, have you had an attack of wheezing after exercising? Yes⎔ No⎔ In the last 12 months, have you had a feeling of tightness in your chest on waking in the morning? ACTIVITY LEVEL
What exercise do you do on a regular basis? How many sessions of exercise (walking, sports, etc.) do you do per week for more than 30 minutes at a How do you feel when exercising? Awful⎔ Average⎔ Excellent⎔ GASTRO ESOPHAGEAL REFLUX / INDIGESTION
Do you have a history of heartburn or indigestion? Yes⎔ No⎔ If yes, how often do you have reflux during the day? ⎔Many times a day ⎔ everyday ⎔ most days Do you suffer heart burn / indigestion during the night? If so how often?⎔ Many times a night ⎔every night ⎔ most nights ⎔ most weeks ⎔ occasionally What aggrevates or causes your reflux? Do you have difficulty swallowing? Yes⎔ No⎔ Details Does food ever get stuck? Yes⎔ No⎔ Details Does food or fluid reflux into the mouth? Yes⎔ No⎔ Details Do you vomit with reflux? Yes⎔ No⎔ Details Do you suffer from recurrent sore throats? Yes⎔ No⎔ Details Do you suffer from a hoarse voice? Yes⎔ No⎔ Details Do you suffer from a regular cough at night? Yes⎔ No⎔ Details Please list any treatments you may use for reflux / heartburn or indigestion



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