Part 1: Medical History
Please check condition that applies to you:
place field "medicalhistoryother" below
place field "hadsurgery" below
place field "sha" below
Select any surgery that applies to you:
place field "othersurgery" below
place field "Barisurgery" below
place field "FH_Anesthesia" below
Indicate any known family history:
place field "FH_Arthritis" below
place field "FH_Asthma" below
place field "FH_Cancer" below
place field "FH_COPD" below
place field "FH_Depression" below
place field "FH_Diabetes1" below
place field "FH_Diabetes2" below
place field "FH_EarlyDeath" below
place field "FH_HeartDisease" below
place field "FH_HighBloodPressure" below
place field "FH_HighCholesterol" below
place field "FH_KidneyDisease" below
place field "FH_MentalIllness" below
place field "FH_MorbidObesity" below
place field "FH_Obesity" below
place field "FH_Stroke" below
place field "FH_ColonPolyps" below
place field "FH_LungCancer" below
place field "FH_OtherCondition" below
place field "FH_OtherConditionPerson" below
place field "ISDIsabled" below
place field "YearsDisabled" below
place field "DisabledReason" below
place field "ReasonDisabledOther" below
place field "AssistiveDevice" below
place field "Yearsinawheelchair" below
place field "Isexercising" below
place field "TypesofExercise" below
place field "exerciseother" below
place field "Exercisetimes" below
place field "ExersizeMinutes" below
place field "FunctionalLimits" below
place field "functionallimitsother" below
place field "consumesalcohol" below
Part 2: Social History
place field "Wine" below
Please indicate the amount you drink each week:
place field "Beer" below
place field "Shots" below
place field "Commentsonalcoholuse" below
place field "drugusage" below
place field "Cocaine" below
How many times/week?
place field "Methamphetamines" below
place field "Inhalants" below
place field "IV" below
place field "DateDruguse" below
place field "CommentsDruguse" below
place field "consumestobacco" below
place field "smokeless" below
place field "TobaccoComments" below
place field "QuitDate" below
place field "SexuallyActive" below
place field "BirthControl" below
place field "BirthcontrolOther" below
place field "hasmedications" below
Part 3: Medications, Vitamins, & Allergies
place field "med1name" below
Please list below all Medications and Vitamins you are currently taking. Ex. Lipitor, 10mg, one tablet daily at bedtime
Please list any allergies and reactions you may have
Part 4: Sleep Assessment
Answer the following questions based on your current sleep situation.
How likely are you to doze off in these situations?
| Situation |
Chance of Dozing |
| Sitting and reading |
place field "WatchingTV" below
|
| Watching TV |
place field "PublicPlace" below
|
| Sitting, inactive in a public place (ex. in a movie theater or a meeting) |
place field "CarPassenger" below
|
| As a passenger in a car for an hour or more |
place field "Lyingdown" below
|
| Lying down to rest in the afternoon |
place field "SittingTalking" below
|
| Sitting and talking |
place field "SittingQuietly" below
|
| Sitting quietly after lunch (without alcohol consumption) |
place field "DrivingaCar" below
|
| While driving a car, while stopped for a few minutes in traffic |
place field "Snoring" below
|
place field "StopBreathing" below
place field "DaySleep" below
place field "ExsessiveSleep" below
place field "Obese5Years" below
Part 5: Weight Loss History
place field "ObeseInChildhood" below
place field "ObeseSincePregnant" below
place field "haswlmeds" below
Tell us about your previous weight loss attempts:
place field "wlmeda" below
place field "wlmedb" below
place field "wlmedc" below
place field "ifFenPhen" below
place field "WLmedother" below
place field "atmonths" below
What diet programs have you tried?
Only document your weight loss attempts in the past 5 years
You have reached the end of the questionnaire, please click submit to take the next steps in your journey.
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