Weight Loss 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.
Have you or anyone in your family been diagnosed with Medullary Thyroid Cancer or Multiple Endocrine Neoplasm Syndrome 2 (MEN-2).	Yes    No
Please list any medications or supplements you have used for weight loss. Include the name, dosage, when you stopped taking it and the reason you stopped taking it.

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?

Exercise

Please describe your exercise habits.

	Activity (Ex. running, cycling, weight lifting)	Minutes Per Session	Sessions Per Week
1.
2.
3.

Weight

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?
Have you ever participated in a weight loss program (Weight Watchers, Noon, Optifast, etc.?) If so, please describe.
Do you use a calorie counting app? If so, which one(s)?

Sleep

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?

Diet

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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