New Patient Questionnaire Template printable pdf download

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New Patient Questionnaire

Page 1 of 4

Service:

 Lap Band

 Gastric Sleeve

 Gastric Bypass

 Optifast/Optitrim

Patient Name: _____________________________________________________________________ Date of Birth: _________________________

Address: ______________________________________________________________________________________________________________

Phone Number: ____________________________________________ Social Security #:

Insurance Company: ________________________________________ Policy #:

Group #: __________________________________________________ Subscriber’s Name:

Relationship to Subscriber: _______________________ Subscriber Social Security #:

Subscriber’s DOB:

Please supply a copy of your insurance card to Regional Weight Management.

E-mail Address: _______________________________________________ Weight:

Height: ___________ BMI: ____________

Primary Provider: ______________________________________________ Surgeon:

 Wesley Sufficool

 William Stone

Employer: _____________________________________________________________________________________________________________

 Full Time

 Part Time

 Self Employed

 Student

Marital Status:

 Single

 Married

 Separated

 Widowed

 Divorced

How did you hear about our program?  Newspaper

 Radio

 Family/friend

 Provider Referral

 Internet

 Other:

What is the best way to contact you?

 Phone

 Email

DIET HISTORY

How long have you been overweight? _______________________________________________________________________________________

What have you done to lose weight? ________________________________________________________________________________________

Have you tried diet pills?  No

 Yes

If yes, brands: _______________________________________________________________________

Are you a yo-yo dieter?

 No

 Yes

Which diet programs apply to you? Select any that you have tried.

 Diet Medications

 Hypnosis

 Optifast

 Air Force Diet

 Medifast

 Slimfast

 Jenny Craig

 Weight Watchers

 TOPS

 Low Calorie Diet

 Overeaters Anonymous

 Self Imposed Fasting

 Subliminal Tapes

 Numerous Book Diets

 Metabolife

 Provider Supervised Diet

 Nutri-System

 Magazine Diets

 High Protein

 Mayo Clinic

 Liquid Protein

 Herbal Life

 Other:

What was your most successful diet program? _______________________________________________________________________________

How much weight did you lose with that program? ____________________________________________________________________________

How quickly did you gain weight afterwards? _________________________________________________________________________________

How many times per day do you eat? ______________________________________________________________________________________

What are your favorite foods? ____________________________________________________________________________________________

Are you a snacker?

 No

 Yes

If yes, how many times daily? _____________________________________________________________

What are your favorite snacks? ___________________________________________________________________________________________

Do you eat a lot of sweets?

 No

 Yes

If yes, how often? ________________________________________________________________

Why do you think you failed with other diet programs? _________________________________________________________________________

_____________________________________________________________________________________________________________________

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New Patient Questionnaire Template

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