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Microsoft word - medicalquestionnaire5pagesfinalversion06131

Name: _______________________________________

Date: _______________
NYU Langone Weight Management Program

Date: _______________________________________________

Last Name:
First Name:____________________________________________

Please mark “x” to all that apply


Medications- Please include ALL medications you take regularly. Please include ALL vitamins, supplements or herbals:

Name of medication
How often?
Start Date

Do you have allergies to medications? If yes, please list:
Do you have an allergy to Latex or surgical tape? If yes, please list: ___________________________________________________________
Have you had any previous surgery? Yes No
Surgery Type

**If you are unclear or do not understand any of the following questions, please leave them blank and a
provider will review them with you**
Angina Assessment

Congestive Heart Failure
Hypertension Ischemic
Page 1 of 5

Name: _______________________________________

Date: _______________
Lower Extremity Edema
Peripheral Vascular Disease (PVD)
Cholelithiasis (Gallstones)
GERD (Gastroesophageal Reflux Disease)
Liver Disease
Abdominal Hernia
associated complication or multiple failed hernia repairs Abdominal Skin/Pannus
Functional Status
Pseudotumor Cerebri
Glucose Metabolism
Page 2 of 5

Name: _______________________________________

Date: _______________
Back Pain
Confirmed Mental Health Diagnosis
Musculoskeletal Disease
Psychosocial Impairment
Alcohol Use
Substance Abuse (Prescription or Illegal Drugs)
Tobacco Use
DVT/PE (Deep vein thrombosis/pulmonary embolism)
If you quit smoking, when did you quit? _____________ Obstructive Sleep Apnea Syndrome
Page 3 of 5

Name: _______________________________________

Date: _______________

Obesity Hypoventilation Syndrome

Menstrual Irregularities (not PCOS)
Pulmonary Hypertension (PH)
Stress Urinary Incontinence
Polycystic Ovarian Syndrome
Bleeding Disorder

Other Medical History-
Please list ALL other medical history or reasons why you currently seek the care of a physician:

Weight Loss Programs:
Please check all programs you have tried IN THE LAST 5 YEARS ONLY.

Wt Loss (lbs)
Wt Loss (lbs)
Page 4 of 5

Name: _______________________________________

Date: _______________
Were you ever treated in an inpatient rehab due to your weight? If yes, where? ___________________________________
Has a physician ever supervised your attempts to lose weight? Yes No
Doctor/Clinic City: Treatment Dates: Type of Treatment:
Have you tried diet pills?

Yes No If yes, please list:___________________________________________________________________________

How long have you been at your present weight?______________ What did you weigh 5 years ago? _____________lbs
What is the most you have ever weighed? ____________ lbs The least? ___________lbs.

Patient Signature:_________________________________ Date: ______________
MD Reviewed: ___________________________________ Date: ________________
Page 5 of 5


Acisclo M Marxuach, MD Evaluation and Management Service Patient Name: JUAN ADORNO ROSARIO EMR Record No: 180-5296 Visit Date: 26-Feb-2013 11:26:00AM Reference#: 60972 Center Record No: 15306 Closing Date: 26-Feb-2013 2:28:48PM Visit Type: Regular Visit (New) Chief Complaint: 31 y/o male with HcvAb+ for the first time in Janb 18, 2013 and claims previous ones have

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