New Patient Medical History Form

Food Insecurity

Within the past 12 months, we were worried whether our food would run out before we got money to buy more? � Yes � No

Within the past 12 months, the food we bought just didn’ t last and we didn’ t have money to get more? � Yes � No

Medical History

Past medical history( check all that apply):
� Gallbladder stones	� Indigestion / reflux	� Thyroid disease	� Diabetes
� High blood pressure	� High cholesterol	� Celiac disease	� Anxiety
� High triglycerides	� Pancreatitis	� Depression	� Bullying
� ADHD	� Bipolar	� Polycystic ovarian syndrome
� Arthritis	� Other:

Past surgical history( check all that apply):
� Gastric bypass	� Gastric banding	� Gastric sleeve	� Gallbladder
� Other:

Allergies:( Medications)_________________________________________________________________________( Food)______________________________________________________________________________

Sleep History

How many hours does your child sleep per night?
Does your child feel rested in the morning? � Yes		� No
Please indicate if your child has any of the following:
� Snoring	� Pauses in breathing		� Waking with dry throat
� Daytime sleepiness	� Sleep apnea / disordered eating		� Nocturnal enuresis
� Night eating

Physical Activity History

Describe the type of physical activity your child engages in: ________________________________________ ________________________________________________________________________________________ Duration: _____ hours _____ minutes

Number of times per week: _____

Does anything limit your child from being physically active?

Patient Label Page 3 of 5

Form Number: 530-206 Revision Date: 7 / 2024

New Patient Medical History Form | Page 3