Cape Fear Physical Medicine Fayetteville, NC Form

First Name:

Last Name:

Date of Birth:

Date of Visit:

Phone: (Home/Cell):

Phone: (Work):

Email:

Gender:

Referred By:

Primary Care Provider:

How does your weight affect your life and health?

How often do you eat breakfast?

Days per week?

Time?

Number of times you eat per day:

What beverages do you drink?

Do you get up at night to eat?

Yes No

If so, how often?

List any food intolerances/restrictions:

Food triggers (check all that apply):

Stress Boredom Anger Insomnia Seeking reward Parties Eating out

Food cravings:

Sugar Chocolate Starches Salty Fast food High fat Large portions

Favorite foods:

Obesity (check all that apply):

Mother Father Sister Brother Daughter Son

Diabetes (check all that apply):

Mother Father Sister Brother Daughter Son

Other (check all that apply):

High blood pressure Heart disease High cholesterol High triglycerides Stroke Thyroid problems Anxiety Depression Bipolar disorder Alcoholism

Cancer (type/s):

Other