NEW PATIENT MEDICAL HISTORY FORM
Name:( First)______________________________( Last) ______________________________( MI)____ Date of Birth: _____/_____/__________ Date of Visit: _____/_____/__________ Phone:( Home / Cell)_______________________( Work) _______________________ Sex: Male Female Transgender( F to M) Transgender( M to F) Gender queer
Choose not to disclose Other gender category not listed Referred By: ______________________________
How does weight affect your child’ s life and health? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________
Weight History
When did you first notice that your child was gaining weight? � Infancy � Childhood � Adolescence � Pregnancy Did your child ever gain more than 20 pounds in less than 3 months? Y / N If so, when? _________ How much did your child weigh: One year ago? _____ Five years ago? _____ Ten years ago? _____ What was your child’ s maximum weight?
Life events associated with weight gain( check all that apply): |
� Marriage of a parent |
� Divorce of a parent |
� Pregnancy |
� Abuse |
� Illness |
� Death of a parent / relative |
� Travel |
� Injury |
� Job change in household |
� Quitting smoking |
� Alcohol |
|
� Change of school |
� Other chronic stress |
|
|
� Medication( please list): _____________________________________________________________ |
What were your child’ s perceived weight change triggers: _____________________________________ ___________________________________________________________________________________
What changes have you already tried to make?( check all that apply): � Commercial weight loss program � Specific Diet( Keto, Atkins, Low-carb, Mediterranean diet, Paleo) � Seen a dietician � Other:
What are your greatest challenges with your child’ s weight? ___________________________________________________________________________________ ___________________________________________________________________________________
Patient Label Page 1 of 5
Form Number: 530-206 Revision Date: 7 / 2024