Tadalafil zeichnet sich durch eine außergewöhnlich lange Halbwertszeit im Vergleich zu anderen PDE5-Inhibitoren aus. Diese pharmakokinetische Eigenschaft führt zu einer verlängerten Exposition des Wirkstoffs im Organismus. Die Eliminationsrate hängt von der hepatischen Aktivität des CYP3A4-Enzyms ab. Lipophile Eigenschaften unterstützen eine weite Verteilung in unterschiedlichen Geweben. Eine ausgeprägte Stabilität gegenüber Nahrungsaufnahme macht den Stoff besonders konstant in seiner Wirkung. Unter generischen Präparaten wird cialis online häufig mit einem vergleichbaren pharmakologischen Profil beschrieben.

Microsoft word - medicalquestionnaire5pagesfinalversion06131

Name: _______________________________________
Date: _______________
NYU Langone Weight Management Program
MEDICAL QUESTIONNAIRE

Date: _______________________________________________

Last Name:
First Name:____________________________________________

FAMILY HISTORY – Please mark “x” to all that apply
FAMILY MEMBER
DIABETES
HIGH BLOOD
PRESSURE
CHOLESTEROL
(indicate

GRAND PARENTS

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

OBESITY RELATED COMORBIDITIES:
**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
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Name: _______________________________________
Date: _______________
GOUT/Hyperuricemia
Fibromyalgia
Back Pain
Confirmed Mental Health Diagnosis
Musculoskeletal Disease
Psychosocial Impairment
Depression
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)
Anonymous
Watchers
 Medifast
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

Source: http://thinforlife.med.nyu.edu/files/thinforlife/attachments/MedicalQuestionnaire5PagesFINALVersion061311.pdf