* are required fields   *Name     Sex Female Male     Date of Birth Month Day Year     Age years     Height ' "  or     m cm     Weight lb.  or   kg     Occupation     *Email     Family History of Obesity Parent Yes No Sibling Yes No Please check as many of the options as apply to you, or fill out the comment fields below.   Cardiovascular: High Blood Pressure Heart Attack Stroke Heart Failure Chest Pain When Walking Varicose Veins Phlebitis-Pulmonary Embolus   Respiratory: Chronic Cough/Emphysema Asthma   Sleep Apnea: Mild Severe   Gastrointestinal: Hiatus Hernia and/or Heartburn Stomach Ulcers Gall stones Chronic Constipation Blood with Bowel Movement Previous Surgery  Dentures Full Upper Lower Partial     Gynecological: Pregnancies Premenstrual Bleeding Menstrual History: Regular Irregular     Endocrine: Thyroid Diabetes Diabetes Therapy (diet/pills/insulin) High Cholesterol/Triglycerides Other Endocrine     Psycho/Social: Eating Disorders (e.g. eat too much) Consultation or Therapy     Musculo - Skeletal:  Joint Pain: Hips Knees Ankles Lower Back Arthrosis: Hips Knees Ankles Lower Back     Any other diseases: Neurological Urinary  Any other diseases:     Drugs: Diet pills (e.g. Phen/Fen) Substance Abuse Smoking   Alcohol drinks/day:     Medications: Prescribed Self-Administered (e.g. Aspirin)     Allergies: Food Medications     Other remarks: Back to the top of the page