Patient Forms
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Lipid Clinic Patient History

Hello!

Welcome to South Dayton Metabolic Center, we are looking forward to your upcoming visit! We ask that you take the time to fill out the attached history form prior to your appointment. Filling this out accurately and completely will help us more quickly zero in on important issues during our appointment and will help focus our discussion. The form may take up to 15-20 minutes to complete so please plan accordingly. Although it is very detailed, we believe this will be a worthwhile investment of your time.

There are a few important reminders about your visit:

- Please arrive 15 minutes early so you can be fully checked in prior to your appointment time.
- Please bring a complete and up-to-date list of all medications and supplements that you are taking. We will go over this with you at the time of check-in.
- If you can’t make your appointment, please contact us at least 24 hours prior to your visit and we can assist you in rescheduling. Please note that appointments in our Weight Loss Clinic may only be rescheduled under certain circumstances.
- If your appointment is in the Weight Loss Clinic, please do not eat, exercise or consume caffeine within 4 hours of your appointment time. This will ensure that we can accurately measure your basal metabolic rate. Non-caloric, decaffeinated beverages like decaf black coffee, unsweetened tea or flavored water are fine to drink

Thank you for choosing SDMC, we are eager to see you in our office. Should you have any questions between now and then, please do not hesitate to contact us!

Sincerely,
Richard Saxen MD

 

Patient History

 
First Name
Last Name
Phone Number
Date of Birth
 
Please describe the health concerns that bring you to our clinic.
Please tell us about your main goal(s) for our visit.
Were you referred by a medical provider? If so, who?
 
 
 

Medical History

 
Please list any current or past medical conditions. Ex: hypertension, diabetes, cancer, car accident, fractures, etc.
Please list all past surgeries and approximate dates.
Please list all current medications, vitamins and supplements. Include dose and how often you take them.
Please list any medication allergies and what type of reaction you experienced.
Please describe any cholesterol medication you were previously taking but are no longer taking. Include the medication's name and dose, when you stopped taking it and why.

Cardiovascular History

 
Have you ever had a heart attack? Yes    No 
Have you eve had a stent placed in your heart? Yes    No 
Have you ever had coronary artery bypass surgery? Yes    No 
Have you ever had a stroke or TIA? Yes    No 
Have you ever had stents placed or surgery on your carotid arteries? Yes    No 
Have you ever had stents placed or surgery on the arteries in your legs? Yes    No 
 
Please provide additional details on any 'Yes' answers from this section.
 
Have you ever had a stress test? Yes    No 
Have you ever had a coronary artery calcium CT scan? Yes    No 
Have you ever had a cardiac catheterization? Yes    No 
 
Please comment on any 'Yes' answers from this section.
 

Family History

 
Family History Heart Attack Stroke Bypass Surgery or Heart Stents High Cholesterol Diabetes High Blood Pressure
Father
Mother
Sibling
Child
Maternal Grandparent
Paternal Grandparent
 
 
Do you have a Medical Power of Attorney? Please bring a copy to your first appointment. Yes    No 
Do you have a Durable Power of Attorney? Please bring a copy to your first appointment. Yes    No 
Do you have a Living Will? Please bring a copy to your first appointment. Yes    No 
 
 

Social History

 
Have you ever smoked regularly?
How many years?
How many packs a day?
When did you stop?
 
How many alcoholic beverages do you consume in an average week?
 
Please describe any current or past recreational drug use.
Are you in a long term relationship?
How many children do you have?
What is your current occupation?
 
 
Please describe your exercise habits.

Activity (Ex. running, cycling, weight lifting) Minutes Per Session Sessions Per Week
1.
2.
3.
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What is your current body weight?
What is your highest body weight in the past 5 years?
What is your lowest body weight in the past 5 years?
What is your target body weight?
 
 
Sleep History
How many hours of sleep do you get on an average night?
On average, how many nights a week do you get less than 7 hours of sleep?
Do you generally feel rested when you wake up and throughout the day?
Have you ever had a sleep study? Yes    No 
Have you ever been recommended to use a CPAP machine? Yes    No 
If yes, are you able to use yout CPAP on a regular basis?
 
 

Obstetric and Gynecological History (if applicable)

 
How many times have you been pregnant?
Have you ever had a miscarriage? If so, how many?
Have you ever had preeclampsia? Yes    No 
Have you ever had a baby born prematurely? Yes    No 
Have you ever had gestational diabetes? Yes    No 
Did you experience menopause before age 40? Yes    No 
 
Please provide additional details on any 'Yes' answers from this section or any other pregnancy related complications you have had.
 

Dietary History

 
Do you attempt to follow a particular dietary pattern? Ex. low carb, vegan, vegetarian, intermittent fasting, etc. If so, please describe.
How many sugar-sweetened beverages do you consume in an average week? Ex. non-diet soda, sweetened coffee/tea, fruit juice, etc.
Approximately how many meals a week are fast food?
Approximately how many meals per week are from a restaurant or take out (not fast food)?
 
 

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