Patient Health Questionnaire Please complete this confidential health questionnaire before your consultation. It takes approximately 7 to 10 minutes. Your answers help the physician understand your health history and determine what options may be appropriate to discuss. Completing this form does not guarantee that medication or any particular treatment will be prescribed.I confirm that I am 18 years of age or older. *YesNoI confirm that the information I provide is accurate and complete to the best of my knowledge. *YesI understand that this form is not for emergencies and does not replace medical care. *YesI consent to The Weight Clinic collecting and reviewing this information for my consultation and related care. *YesName *Email Address *Phone *Date of Birth *Sex assigned at birth *Please select an optionFemaleMaleIntersexPrefer not to sayCurrent weight (lb) *Height (inches) *Goal weight (lb)What was your highest adult weight (lb)?What was your lowest adult weight (lb)?Have you tried to lose weight before? *YesNoWhich weight-loss approaches have you tried?Diet changesExerciseWeight-loss medicationWeight-loss injectionsCommercial weight-loss programmeOtherPlease tell us what has worked for you in the past and what has been difficult to maintain.Have you previously used prescription medication or injections for weight loss? *YesNoIf yes, please list the medication(s), approximately when you used them, and your experience with them.Have you ever been diagnosed with any of the following? *Type 2 diabetesPrediabetesHigh blood pressureHigh cholesterolHeart diseaseStroke or TIAKidney diseaseLiver diseaseGallbladder disease or gallstonesPancreatitisThyroid diseaseSleep apneaPCOSDepressionAnxietyEating disorderNone of the aboveOtherPlease list any other medical conditions or significant health problems.Have you ever had weight-loss or bariatric surgery? *YesNoIf yes, please provide details.Have you ever been diagnosed with gastroparesis or another condition that significantly slows stomach emptying? *YesNoUnsureHave you ever had pancreatitis? *YesNoUnsureHave you ever had gallstones or gallbladder disease? *YesNoUnsurePlease list all medications you currently take, including prescription medications, over-the-counter medicines and supplements. *Please list any medication allergies or other allergies. *Have you or a family member ever been diagnosed with medullary thyroid cancer? *YesNoUnsureHave you or a family member ever been diagnosed with Multiple Endocrine Neoplasia type 2 (MEN 2)? *YesNoUnsureAre you currently pregnant, breastfeeding, or trying to become pregnant? *YesNoNot ApplicableAre you currently taking another GLP-1 or weight-loss medication? *YesNoUnsureHow would you describe your current level of physical activity? *Very littleLightModerateHighHow would you describe your usual eating pattern? *Generally balancedSometimes difficult to manageFrequently difficult to manageUnsureDo you currently smoke or use nicotine products? *YesNoFormerlyDo you drink alcohol? *YesNoIf yes, approximately how much alcohol do you drink in a typical week?Do you currently use recreational drugs or non-prescribed substances? *YesNoIs there anything about your mental health, eating habits or relationship with food that you would like Dr. Gordon to know?What are your main goals for treatment? *Lose weightImprove blood sugar or metabolic healthImprove energyImprove mobility or physical activityReduce health risksMaintain weight already lostOtherWhat would a successful outcome from treatment look like for you?Is there anything else you would like Dr. Gordon to know before your consultation?Recent laboratory results or other relevant medical documentsChoose FileNo file chosenDelete uploaded fileI confirm that the information provided in this questionnaire is accurate and complete to the best of my knowledge *YesI understand that completing this questionnaire does not guarantee that medication or any particular treatment will be prescribed. *YesSubmit
