Medical Forms

Step 1 of 4

25%

LOUISVILLE CENTER FOR WEIGHT LOSS

Medical History Form

Name

Age

Sex

Male

Female

Phone

Family Provider

Present Status:

1. Are you in good health at the present time to the best of your knowledge?

Yes

2. Are you under a provider’s care at the present time?

Yes

If yes, for what?

3.Are you taking any medications at the present time?

Yes

What

Dosages

What

Dosages

4. Any allergies to any medications?

Yes

5. Any allergies to any medications?

Yes

6. History of Diabetes?

Yes

At what age:

7. History of Heart Attack or Chest Pain?

Yes

8. History of Swelling Feet

Yes

9. History of Frequent Headaches?

Yes

Migraines?

Yes

Medications for Headaches:

10. History of Constipation (difficulty in bowel movements)?

Yes

11. History of Glaucoma?

Yes

12. Gynecologic History:

Name

First Last

Pregnancies:

Number:

Dates

MM slash DD slash YYYY

Natural Delivery or C-Section (specify):

Pregnancies:

Onset:

Duration:

Are they regular:

Yes

Pain associated:

Yes

Last menstrual period:

Hormone Replacement Therapy:

Yes

What:

Birth Control Pills:

Yes

Type:

Last Check Up:

13. Serious Injuries:

Yes

Specify:

Date

MM slash DD slash YYYY

14. Any Surgery:

Yes

Specify:

Date

MM slash DD slash YYYY

Specify:

Date

MM slash DD slash YYYY

15. Family History:

Father

Age

Health

Column 3

Column 4

Column 5

Mother

Age

Health

Column 3

Column 4

Column 5

Brothers

Age

Health

Column 3

Column 4

Column 5

Sisters

Age

Health

Column 3

Column 4

Column 5

Has any blood relative ever had any of the following:

Glaucoma:

Yes

Who:

Asthma:

Yes

Who:

High Blood Pressure:

Yes

Who:

Epilepsy:

Yes

Who:

Kidney Disease:

Yes

Who:

Diabetes:

Yes

Who:

Tuberculosis:

Yes

Who:

Psychiatric Disorder:

Yes

Who:

Heart Disease/Stroke

Yes

Who:

Past Medical History:

Polio

Jaundice

Kidneys

Lung Disease

Rheumatic Fever

Ulcers

Anemia

Tuberculosis

Drug Abuse

Pneumonia

Cholera

Arthritis

Measles

Mumps

Scarlet Fever

Whooping Cough

Bleeding Disorder

Gout

Heart Valve Disorder

Gallbladder Disorder

Eating Disorder

Malaria

Cancer

Osteoporosis

Tonsillitis

Pleurisy

Liver Disease

Chicken Pox

Nervous Breakdown

Thyroid Disease

Heart Disease

Psychiatric Illness

Alcohol Abuse

Typhoid Fever

Blood Transfusion

Other

(check all that apply)

Other

Nutrition Evaluation:

1. Present Weight

Height (no shoes):

Desired Weight:

2. In what time frame would you like to be at your desired weight?

3. Birth Weight:

Weight at 20 years of age:

Weight one year ago:

4. What is the main reason for your decision to lose weight?

5. When did you begin gaining excess weight? (Give reasons, if known):

6. What has been your maximum lifetime weight (non-pregnant) and when?

7. Previous diets you have followed:

Give dates, weight loss, compliance:

8. Is your spouse, fiancee or partner overweight?

Yes

9. By how much is he or she overweight?

10. How often do you eat out?

11. What restaurants do you frequent?

12. How often do you eat “fast foods?”

13. Who plans meals?

Cooks?

Shops?

14. Do you use a shopping list?

Yes

15. What time of day and on what day do you shop for groceries?

16. Food allergies:

17. Food Dislikes:

18. Food you crave:

19. Any specific time of the day or month do you crave food?

20. Do you drink coffee or tea?

Yes

How much daily?

21. Do you drink cola drinks?

Yes

How much daily?

22. Do you drink alcohol?

Yes

What?

How Much?

Weekly?

23. Do you use a sugar substitute?

Butter?

Margarine?

24. Do you awaken hungry during the night?

Yes

What do you do?

25. What are your worst food habits?

26. Snack Habits: What?

How Much?

When?

27. When you are under a stressful situation at work or family related, do you tend to eat more? Explain:

28. Do you thing you are currently undergoing a stressful situation or an emotional upset? Explain:

29. Smoking Habits: (answer only one)

You have never smoked cigarettes, cigars or a pipe

You quit smoking ___ years ago and have not smoked since.

You have quit smoking cigarettes at least one year ago and now smoke cigars or a pipe without inhaling smoke

You smoke 20 cigarettes per day (1 pack).

You smoke 30 cigarettes per day (1-1/2 packs).

You smoke 40 cigarettes per day (2 packs).

30. Typical Breakfast

Time eaten:

Where:

With Whom:

31. Describe your usual energy level:

32. Activity Level: (answer only one)

Inactive⎯no regular physical activity with a sit-down job

Light activity⎯no organized physical activity during leisure time

Moderate activity⎯occasionally involved in activities such as weekend golf, tennis, jogging, swimming or cycling.

Heavy activity⎯consistent lifting, stair climbing, heavy construction, etc., or regular participation in jogging, swimming, cycling or active sports at least three times per week.

Vigorous activity⎯participation in extensive physical exercise for at least 60 minutes per session 4 times per week.

33. Behavior style: (answer only one)

You are always calm and easygoing.

You are usually calm and easygoing.

You are sometimes calm with frequent impatience.

You are seldom calm and persistently driving for advancement.

You are never calm and have overwhelming ambition.

You are hard-driving and can never relax.

34. Please describe your general health goals and improvements you wish to make:

This information will assist us in assessing your particular problem areas and establishing your medical management. Thank you for your time and patience in completing this form.

LOUISVILLE CENTER FOR WEIGHT LOSS

New Patient Medical Information

Date

MM slash DD slash YYYY

Name

Age

Do you have any medical problems?

High blood pressure , Diabetes , Asthma

Are you allergic to any medicines?

Penicillin

Have you had any surgeries?

Appendix

Gall Bladder

Hysterectomy

Please list any medicines you take:

Please list any hospitalizations:

Do any diseases run in your family?

Diabetes

High blood pressure

Heart problems

Do you smoke?

Yes

Drink

Yes

Do you have a living will?

Yes

Are your immunizations up to date

Yes

Why are you here today?

Please list any other symptoms or health concerns which you may be having:

LOUISVILLE CENTER FOR WEIGHT LOSS

Patient Information Form

Date

MM slash DD slash YYYY

Acct #

Patient

Name

Date

MM slash DD slash YYYY

Telephone

Address

Street Address Apt City State / Province / Region ZIP / Postal Code

Marital Status

Single

Married

Divorced

Widowed

Sex

Race

Employer

Occupation

Social Security #

Employer's Address

Work Telephone

Preferred Language

SPOUSE

Name

Date

MM slash DD slash YYYY

Acct #

Employer

Occupation

Social Security #

Employer’s Address

Work Telephone

CHILDREN

List

Name

Date of Birth

INSURANCE

Name

Relationship

Work Phone

Home Phone

Referred By:

Provided

Friend/Relative

Telephone Book

Other

Name

Address

Phone

IN CASE OF EMERGENCY CONTACT:

Primary Ins. Co

Policy No.

Group No.

Claims Processing Address

Telephone

Insured Name

Relationship to Patient

Secondary Ins. Co

Employer

Comments

Secondary Ins. Co

Policy No.

Group No.

Claims Processing Address

Telephone

Insured Name

Relationship to Patient

Employer

Comments

Is this visit due to an employment-related or auto accident?

Yes

Date of Injury

MM slash DD slash YYYY

Nature and Location of Accident

PERMISSION FOR TREATMENT: Permission is hereby granted to George C. Stege, III, M.D., to render such medical and surgical treatment as is deemed necessary.

RELEASE OF INFORMATION: To the extent necessary to determine insurance benefits, liability for payment and to obtain reimbursement, George C. Stege 111, M.D. may disclose portions of the patient’s medical record and account to any person or corporation which is or may be liable for all or any portion of the patient’s charges including but not limited to insurance companies, health care service plans, or worker’s compensation carriers. The patient’s medical record may also be released to the referring provider to ensure continuity of medical care.

FINANCIAL AGREEMENT: In consideration of the services rendered to the patient, the undersigned agrees to accept full financial responsibility for the patient’s account in accordance with the regular rates and terms of the facility. Should the account be referred for collections, the undersigned shall pay reasonable attorney’s fees and collection expenses. Louisville Center for Weight Loss does not participate with any insurance companies and you are responsible for all charges. As a courtesy we will provide you with the information to file an out of network claim.

ASSIGNMENT OF INSURANCE BENEFITS: I request my insurance carrier to pay to George C. Stege, III, M.D. all benefits due me related to my pending claim for medical and surgical services.

MEDICARE S AUTHORIZATION: I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers, or to the billing agent of this provider or supplier, any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment.

I have read and approved all of the above except for those items I have personally lined through and initialed.

Signature

Date

MM slash DD slash YYYY

LOUISVILLE CENTER FOR WEIGHT LOSS

Review of systems

Loss of hearing

Yes

Ringing in the ears

Yes

Ear infection

Yes

Bad vision

Yes

Eye pain

Yes

Eye infections

Yes

Nose bleeds

Yes

Sinus problems

Yes

Sore throat

Yes

Hoarseness

Yes

Shortness of breath

Yes

Back pain

Yes

Rash

Yes

Insomnia

Yes

Memory loss

Yes

Dizzy spells

Yes

Palpitations

Yes

Irregular pulse

Yes

Swelling

Yes

Fainting spells

Yes

Chest pain

Yes

Numbness

Yes

Loss of appetite

Yes

Indigestion

Yes

Diarrhea

Yes

Constipation

Yes

Bloody or tarry stools

Yes

Nervousness

Yes

Depression

Yes

Moodiness

Yes

Phobias

Yes

Hemorrhoids

Yes

Blood in urine

Yes

Frequent urination

Yes

Hernia

Yes

Sudden weight loss

Yes

Fatigue

Yes

Convulsions

Yes

Headache

Yes

Joint pain

Yes

Paranoia

Yes

Psychosis

Yes

Chemical Dependency

Yes

Cardiovascular Disease

Yes

LOUISVILLE CENTER FOR WEIGHT LOSS

Sjogrens CAGE Questionaire

Dry or Itchy eyes

Yes

I find myself rubbing my eyes often because they feel dry. I use over the counter eye drops several times a day/more than the recommended amount

Dry mouth

Yes

I find myself rubbing my eyes often because they feel dry. I use over the counter eye drops several times a day/more than the recommended amount

Difficulty talking chewing or swallowing

Yes

My mouth hurts when I chew or swallow food. I find it difficult to chew and/or swallow dry foods like crackers

Sore or cracked tongue

Yes

My tongue often feels like sandpaper, and is very dry and scratchy. My tongue sometimes feels sore

Oral yeast infections, such as candidiasi

Yes

I have had several oral yeast infections over the last year

Increased dental cavities

Yes

Even though I brush and floss, I seem to be experiencing more oral health problems than usual. I seem to have more tooth decay and cavities than ever before

Increased dental cavities

Yes

Even though I brush and floss, I seem to be experiencing more oral health problems than usual. I seem to have more tooth decay and cavities than ever before

Extreme fatigue or drowsiness

Yes

I have cancelled plans or stopped what I’m doing because I feel too tired

Joint pain or soreness

Yes

I find myself rubbing my eyes often because they feel dry. I use over the counter eye drops several times a day/more than the recommended amount

I have been diagnosed with fibromyalgia

Yes

For every new patient LCWL will donate $1 to the Sjogren’s Syndrome Foundation
For more information on Sjogren’s Syndrome please go to www.sjogrens.com

For every new patient LCWL will donate $1 to the Sjogren’s Syndrome Foundation
For more information on Sjogren’s Syndrome please go to www.sjogrens.com

Drug Alcohol Screening

Have you felt the need to Cut down on your drinking?

Yes

Do you feel Annoyed by people complaining about your drinking?

Yes

Do you ever feel Guilty about your drinking?

Yes

Do you ever drink an Eye-opener in the morning to relieve shakes?

Yes

Do you use any illegal drugs?

Yes

Signature

Date

MM slash DD slash YYYY

LOUISVILLE CENTER FOR WEIGHT LOSS

Sleep Apnea Quiz

Has anyone observed that you have stopped breathing while sleeping?

Yes

Do you snore loudly?

Yes

Do you often feel tired, fatigued, or sleepy during the day?

Yes

Do you often awake with a dry mouth?

Yes

Do you frequently awaken with headaches?

Yes

Do you have or are you being treated for high blood pressure?

Yes

Do you often feel irritable or moody during the day?

Yes

Are you currently gaining weight?

Yes

Are you currently gaining weight?

Yes

Are you overweight?

Yes

If you answered YES to THREE or more questions, you may have sleep apnea, a common yet serious condition that can result in poor sleep quality, daytime fatigue, depression, irritability and memory problems. Left untreated, sleep apnea can also lead to heart disease and an increased risk of dangerous accidents.

Additionally, if you SNORE and answered YES to any of the above and have a history of TIA, stroke, high blood sugar, or are taking medications for diabetes, please discuss your significant risk of sleep apnea with your doctor.

2304 Hurstbourne

(502) 583-3189

Hours

ADDRESS

CONTACT US

HOURS

Medical Forms

LOUISVILLE CENTER FOR WEIGHT LOSS

Medical History Form

LOUISVILLE CENTER FOR WEIGHT LOSS

New Patient Medical Information

LOUISVILLE CENTER FOR WEIGHT LOSS

Patient Information Form

Patient

SPOUSE

CHILDREN

INSURANCE

IN CASE OF EMERGENCY CONTACT:

LOUISVILLE CENTER FOR WEIGHT LOSS

Review of systems

LOUISVILLE CENTER FOR WEIGHT LOSS

Sjogrens CAGE Questionaire

LOUISVILLE CENTER FOR WEIGHT LOSS

Sleep Apnea Quiz

Talk To Us

ADDRESS

OPERATING

CONTACT

QUICK LINKS

OUR SERVICES

On-site Pharmacy

East Broadway Pharmacy

Address

Office Hours

Phone

Email

Jamal Aboulhosn, RPH