Place label Here

Patient Name
Clinical
Nutrition
New Patient
Form
Primary Care
Physician
What is your name?
What is your address?
What is your reason for your visit?
Please describe your problem from the frst sign/symptom, including location,
severity, duration, and
associated factors, etc.
Im going to told you some questions for your Personal Diet History
What was your age of frst diet?
What was your weight at puberty
!"inny Normal #hubby
What was your weight at $%?
What was your height at $%
Pre&marriage weight 'ge
(ver lost or regained $%lbs? )es No
How many times?
What was your heaviest weight?
When
What was your lightest weight?When
*o you consider yourself a +BINGE
E!E",?
)es No
*escribe a typical binge below
Pregnancies Weight -ained Weight .oss *ate/)ear
/
st
$
nd
0
rd
1
th
Ha#e you e#er used the following methods for weight loss$
%ethod &es No 'hen %ethod &e
s
No 'hen
2omiting *iet Pill/Prescription
Water Pills *iet Pills/3ver the #ounter
4pecac (5cessive (5ercising
.a5atives
Please list all the diet (rograms you ha#e (re#iously attem(ted and
a((ro)imate dates$
Have you ever been on a diet?
How long did it ta"e?
What was the last time that you were on a diet?
How many "ilograms did you lose?
How much time did you again your weight again?
%edicatio
ns
Have you ever ta"en any medications to lose weight?
What was the dosage to that medication?
Did you ha#e any
allergies*
Nam
e
6eactio
n
Ha#e you e#er +een hos(itali,ed for any serious disease*
Why?
-ocial
History
're you married or
single?
!ingle7777 !eparated7777 *ivorced77777
Widowed7777
*o you live with someone or alone?
'lone !pouse/!ignifcant
3ther 8riend Parent
#hildren 3ther
8amily
What is your 3ccupation?
*o you en9oy your wor"?
*id you have 6ecreational 'ctivities?
*id you have any Hobbies?
DID YOU USE..?
Neve
r
)es/What :ind 'mount/)ears ;uit/When
<obacco
'lcohol
*rug
*4* )3=
#3N!=>(?? #a@eine
#offee
!oda
#hocola
te
Have you ever been physically or se5ually abused?
*o you e5ercise? )es No 4f yes, what type?
How many <imes per wee"? How long?
Family History
-heet$
Please answer and chec. o/ the +o)es that a((ly to
WHAT IS
YOUR?
>other 8ather !iblings
/ How
many
#hildren
/ How
many
>aterna
l
-randmoth
er
>aterna
l
-randfath
er
Patern
al
-randmoth
er
Patern
al
-randfath
er
!pouse
Height
>a5imum
Weight
>inimum
Weight
DO YOU
HAVE.?
*iabetes
Heart
*isease
(levated AP
*2</P(
Bblood clotC
!tro"e
'rthritis
'sthma
<hyroid
*isease
-out
(ating
*isorder
>ental
4llness
Physical/
!e5ual
'buse =lcers
:idney
*isease
#ancer
'lcohol/
*rug 'buse
!tate of
Health if
.iving/'ge
#ause of
*eath/'ge
*o you have any Duestions or issues you would li"e to discuss with me/us regarding family
history?
%edical
History
Ha#e you e#er e)(erienced any of the following medical (ro+lems*
&e
s
No &e
s
No &e
s
No &e
s
No
!tro"e (ye <rouble 6heumatic
8ever
Alood
*isorder
!eiEure
*isorder
Pneumonia .iver *isease Alood
<ransfusion
=nconsciousne
ss
(mphysema -erd
(sophageal
6eflu5
Aro"en Aones
'n5iety/
*epression
'sthma -allbladder
*isease
'rthritis
3ther >ental
4llness
!leep 'pnea *iverticulitis -out
*2</P(
BAlood #lotC
High Alood
Pressure
:idney !tones =rinary <ract
4nfection
!"in #ancer High
#holesterol
:idney *isease 2enereal
*isease
3ther <ypes of
#ancer
Heart >umur <hyroid
*isease
Areast .ump
6adiation
<reatment
(nlarged Heart 'nemia (5posed to
<A
-laucoma Heart 'ttac" *iabetes Hay 8ever
Then observe and I will play the following parts of your body to identify nutrient deficiencies.
(5am
Normal
(yes #on9unctivae/lids
Pupils/4ris
3phthalmoscopic (5am
(N>< (5t. (ars/Nose
(5t. 'udo
Hearing
Nasal >ucosa, !eptum, <urbinetes
.ips/<eeth/-ums
3ropharyn5
Nec" Nec"/<hyroid
6(!P 6esp e@ort
Percussion of chest Palpation of chest
'uscultation of lungs
#ardio Palpation of Heart
'uscultation of Heart
(5amination of #arotid and 8emoral arteries,
abdominal aorta, pedal pulses, e5tremities for
edema/varicosities
#hest/Areast
s
Areasts
Palpation of breasts and a5illary
-4 'bdomen
.iver and !pleen
Hernia
'nus, perineum/rectum
3btained stool sample
-= %0E
!crotal contents
Penis
*igital rectal e5am
FE%0E
(5t. henitalia
=rethr
a
Aladd
er
#ervi5
=terus
.ymph Palpation of nodes in $ or more areas
Nec"
'5illa
c
-roin
3the
>usculo -ait and station
*igits and nails
3ne or more of the F areas
Head and nec"
!pine, ribs and
pelvis 6ight
upper e5tremity
.eft upper
!"in !"in and subcutaneous tissue
Palpate s"in and subcutaneous tissue
Neuro <est cranial
nerves *eep
tendon refle5es
!ensation
Psych *escription of 9udgement and insight
Arief assessment of mental
status 3rientation to time
place and person 6ecent and
remote memory
>ood and a@ect