Medication History:
Has your child ever taken medication to lose weight?( check all that apply): |
� Phentermine( Adipex) |
� Meridia |
� Xenecal / Alli |
� Metformin |
� Contrave |
� Topamax |
� Saxenda |
� Victoza |
� Bupropion( Wellbutrin) |
� Ozempic |
�Trulicity |
� Qsymia |
Other( including supplements): __________________________________________________________ |
What worked? _______________________________________________________________________ |
What didn’ t work? ____________________________________________________________________ |
Why or why not? _____________________________________________________________________ |
Medications( list all current medications, including over-the-counter medications, supplements, and herbs): ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________
Nutritional History How often does your child eat breakfast? _____ days per week at _____:_____ a. m. Number of times your child eats per day: _____ What beverages do they drink? ____________________ Do you get up at night to eat? Y / N If so, how often? _____ times List any food intolerances / restrictions: _____________________________________________________ Food triggers( check all that apply): � Stress � Boredom � Anger � Insomnia � Seeking reward � Parties � Eating out � Other: _______________________
Food cravings: |
� Sugar |
� Chocolate |
� Starches |
� Salty |
� Fast food |
� High fat |
� Large portions |
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Favorite foods: _______________________________________________________________________ |
Behavior
Does your child display“ out of control” behavior towards eating?( eating too much,“ hungry” all the time, sneaking food) � Yes � No
Do you need help with establishing boundaries for food / eating? � Yes � No Do you think your child eats due to sadness, boredom and / or loneliness? � Yes
� No
Has your child or your family experienced recent trauma or stress that you feel may be contributing to current health concerns? � Yes � No
Describe:
Has there ever been a diagnosis of an eating disorder? |
� Yes |
� No |
If yes, which one? |
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Patient Label Page 2 of 5
Form Number: 530-206 Revision Date: 7 / 2024