Weight No More! Medical Director:“Now is the time for a trimmer, healthier you.” Peter Ruggiero, M.D

Bariatric Physical Exam

Name:______________________________ Age:__________ Date:___________

Vital Signs: BP (sitting) ____________ Pulse__________

Height (w/o shoes) ____________ inchesWeight (w/o shoes) _____________ lbs.Preliminary Goal Weight________________

B.M.I. ___________ Waist Circumference______________ Hip Circumference________Body Composition Analysis Completed and Review [ ]_____________ % fat_________W/H Ratio _________________________ Frame/Shape_______________________Body Composition Analysis Completed and Review [ ] ________ % fat______ % lean______ECG Completed and Reviewed [ ] [ ] Normal [ ] Abnormal

Medical HistoryReview of Systems: Please Circle1. Are you in good health at the present time? Yes No2. Are you under a doctor’s care? Yes No If yes, for what? Who is your primary care physician?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. Are you taking any medications at the present time? Yes No If yes please list all mediations and dosages: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. Are you allergic or sensitive to any medications? Yes No If yes please list those medications here.________________________________________________________________________________________________________________________________________________5. History of High Blood Pressure? Yes No

6. History of Diabetes? Yes No At what age:_______________

7. History of Heart Attack or Chest Pain? Yes No Please provide detail of heart attach and any intervention (e.g. by-pass surgery, angioplasty, stent placement)____________________________________________________________________________________________________________________________________________________________________________________

8. History of thyroid disease or abnormalities? Yes No

9. History of frequent headaches or migraines? Yes No

10. History of constipation (di�culty in bowel movements)? Yes No

11. History of Glaucoma? Yes No

12. Have you been previously treated by a physician for weight management? Yes NoPlease explain (e.g. prescribed diets, medications or surgical interventions).________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. Have you taken, or are you currently taking any stimulant drugs or appetite suppressants, including over the counter energy preparations? Please explain.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

14. Is there any history of psychiatric illness, requiring treatment? Yes No Please explain and list any medications that have been prescribed for your condition (e.g. depression, anxiety, bipolar disorder).________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past Medical History: (check all that apply)_____ Kidney Disease _____ Scarlet Fever _____ Osteoporosis_____ Lung Disease _____ Jaundice _____ Blood Transfusion_____ Rheumatic Fever _____ Bleeding Disorder _____ �yroid Disease_____ Ulcers _____ Gout _____ Heart Disease _____ Anemia _____ Heart Valve Disorder _____ Psychiatric Illness_____ Tuberculosis _____ Gallbladder Disorder _____ Alcohol Abuse _____ Drug Abuse _____ Eating Disorder _____ Other:_____________ Pneumonia _____ Arthritis_____ Cancer _____ Liver Disease

Nutrition Evaluation:1. Present Weight: __________ Height (no shoes) :_________ Desired Weight: __________2. What time frame would you like to be at your desired weight? _____________________3. What 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: Please give dates and results of your weight loss:___________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ ____________________________________8. Is your spouse, �ancée or partner overweight? Yes No9. By how much is he or she overweight? ________________________________________10. How o�en do you eat out? ________________________________________________11. What restaurants do you frequent? __________________________________________12. How o�en do you eat “fast foods?”__________________________________________13. Who plans meals? ______________________________________________________ ______________________ shops___________________ cooks_________________14. Do you use a shopping list? Yes No15. What time of day and what time do you shop for groceries? ______________________16. Food allergies: ________________________________________________________17. Food dislikes: ________________________________________________________18. Foods you crave: _____________________________________________________19. Any speci�c time of the day or month when you crave food?______________________20. Do you drink ca�einated beverages? Yes No If yes please give examples of daily amounts: ___________________________________________________________________________________________________________________________________________________________________________________21. Do you eat chocolate to excess? ________________________ Yes No How much daily? _______________________________________________________22. Do you drink alcohol? Yes No What? __________________ How much? _____________ Frequency?___________23. Do you use a sugar substitute? Yes No If yes what type and how much? ___________________________________________ Do you use butter? Yes No Do you use margarine? Yes No24. Do you awaken hungry during the night? Yes No25. What are your worse food habits? ________________________________________________________________________________________________________________________________________________________________________________________________________________________26. Snack habits: What and how much? When do you eat these snacks?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________27. When you are under a stressful situation at work or family related, do you tend to eat more?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________28. Do you think you are currently under going a stressful situation or an emotional upset? Explain:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

29. Typical Breakfast Typical Lunch Typical Dinner_________________ _______________ ______________________________________ _______________ _______________________________________ ________________ _______________________________________ ________________ ______________________________________ _________________ _____________________

Time eaten: _______ Time eaten:_______ Time eaten:___________ Where: __________ Where: ________ Where:_____________With whom:_______ With whom:_____ With whom:_________

30. Describe your usual energy level:____________________________________________31. Activity Level: (Please mark only one) ___Inactive - no regular physical activity, e. g.: 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 li�ing, 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 lease 60 minutes per session,

4 times per week.32. Behavior style: (mark 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 driven and can never relax.33. Please describe your general health goals and improvements you wish to make:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Plan:[ ] Diet Discussed_______________________________________________________[ ] Exercise Prescription Discussed __________________________________________[ ] Counselor/�erapist Refer To: ____________________________________________[ ] Behavior Lifestyle Discussed _____________________________________________[ ] Medications _________________________________________________________[ ] Side E�ects[ ] Informed Consent Signed[ ] Waiver of Childproof Signed [ ] Bill of Rights signed and witnessed�is information will assist us in assessing your particular problem areas and establish your medical management. �ank you for your patience in completing this form.

Reviewed:Peter Ruggiero M.D._____________________________ Date: ___________________