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Aleksandr Benji FNP98-71 Queens Blvd, Rego Park NY 11374646-301-4000Weight Loss Intake FormName:Date of BirthALLERGIES (Please list any food, drug, or medication hypersensitivities or allergies you experience.Please include reaction.)Sulfa AllergySoy Allergy Topical Anesthetic AllergySpecifyMEDICATIONSCurrent medications (vitamins, birth control pills)Mood-altering or depression medicationSKIN ASSESSMENTDo you have any of the following concerns? (Check all that apply.)Fine LinesDeep WrinklesUnder eye CirclesSagging SkinDark SpotsRough skin textureLarge poresSagging cheek bonesStretch marksScars (acne or surgical)NoneOther:MENSTRUAL / BIRTHING HISTORYIs it possible you may be pregnant? Yes NoIf “Yes” How far along?Last Menstrual CycleAge of first MensesItching or burning# of Pregnancies# of Days of MensesBleeding between periods Yes No# of MiscarriagesLength of CycleBleeding after intercourse Yes No# of Live Births# of AbortionsIrritation or dischargeWeight Loss Intake FormPage 1 of 8Yes NoYes No
FAMILY HISTORY (Check all health conditions that apply.)FatherMotherBrother(s)Sister(s)Age (if living)Health (G Good / P Poor)CancerDiabetesHeart DiseaseHigh Blood PressureStrokeMental IllnessAsthma/Hay Fever/HivesKidney DiseaseAge (at Death)Cause of DeathGENERAL HEALTHWhen and where did you last receive health care?For what reason?Do you have any infectious diseases? Yes NoIf “Yes” Please IdentifyWhat was your most recent blood pressure reading? /Date taken / /Do you currently have any medical concerns? Please listHave You Been Able To Follow Prescribed Medications/Treatments? Yes NoIf “No” why not?Weight Loss Intake FormPage 2 of 8
Have you been diagnosed with or had any of the following conditions (past or present)?Please check all that apply.HepatitisHeadachesScoliosisBrain FogNeck PainFatigueBack PainFeverShoulder PainLeg PainInsomniaHeart MurmurDepressionDiabetesSpasms/CrampsHot FlashesTendonitisAsthmaChest PainOsteoporosisDizzinessAnxietyHeart DiseaseAbdominal PainStrokeCancerBlood ClotsGas/BloatingHigh mbness/tinglingConstipation/DiarrheaShortness ofBreathArthritis/Stiff/Painful JointsRash/skin problemsBladder/Kidney DiseaseSciatica/Shooting painPlease provide more explanation about all that you checked.Have you been diagnosed with or had any of the following digestive disorders (past or present)?Please check all that apply.NauseaVomitingDiarrheaBlood in stoolBloating/GasABD DistentionConstipationIncomplete EvacuationSmall Round StoolHard StoolABD crampingSignificant Residual When WipingDIGESTIVE HEALTH / BOWEL MOVEMENT (BM) CHARACTERISTICSNumber of BM times per day:1234If don’t typically have a daily BM how often do you evacuate?1-2 times per week3-4 per week5-6 per weekless than once a weekDoes it feel like there is more feces stuck in you after having bowel movement? Yes NoDo you eat a diet low in fiber? Yes NoDoes your diet include a lot of meat/cheese or processed foods? Yes NoWeight Loss Intake FormPage 3 of 8
Do you suffer from incontinence? Yes NoDo you experience pain upon defecation? Yes NoDo you experience blood in your stool? Yes NoDo you have hemorrhoids? Yes NoWhen was your last bowel movement?What BM interventions do you use? None Laxatives Enemas OtherEXAMINATIONS HISTORYDate of last physical examination ReasonHospitalization Dates and ReasonsX-Rays: ChestStomachGallbladderKidneyColonOtherDate of last laboratory testsData of last electrocardiogram (heart tracing)Date of last pap (cancer smear)WEIGHT HISTORYWhen did you first become overweight? (Year) (Your age then)How did your weight gain start? Describe the circumstancesWhat do you think is the cause of your weight problem?Your present weight Your weight goal Your heightWhat was your highest weight? (excluding pregnancy) Your age thenWhat was your lowest weight? your age then # of years ago:Have you ever stayed the same weight for 10 years or more? Yes NoHave you attempted to lose weight before? Yes NoMost lbs lost How long it tookDescribe your previous weight loss methods (e.g. diets, pills, injections, hypnosis, acupuncture) and resultsWeight Loss Intake FormPage 4 of 8
ENERGY AND IMMUNITYDo you have any of the following concerns? (Check all that apply.)FatigueSlow Wound HealingChronic InfectionsLyme DiseaseChronic FatigueCandida / Yeast InfectionsEMOTIONAL/PSYCHIATRICDo you have any of the following concerns? (Check all that apply.)Mood SwingsNervousnessMental TensionIrritabilityDepressionGriefHEAD, EYE, EAR, NOSE, THROATDo you have any of the following concerns? (Check all that apply.)Impaired VisionEye Pain/ StrainGlaucomaGlasses/ContactsImpaired HearingEar RingingEarachesHeadachesNose BleedsFrequent Sore ThroatsTeeth GrindingTMJ/Jaw ProblemsTearing/DrynessSinus ProblemsHay FeverRESPIRATORYDo you have any of the following concerns? (Check all that apply.)PneumoniaFrequent Common ColdsDifficulty BreathingPleurisyAsthmaTuberculosisPersistent CoughEmphysemaShortness of BreathCARDIOVASCULARDo you have any of the following concerns? (Check all that apply.)Heart DiseaseChest PainSwelling of AnklesHigh BP PalpitationsFlutteringStrokeBruisingHeart MurmursRheumatic FeverVaricose VeinsAbnormal BleedingPain in CalvesGASTROINTESTINALDo you have any of the following concerns? (Check all that apply.)UlcersChanges In AppetiteNausea/VomitingEpigastric PainHeartburnGallbladder DiseaseLiver DiseaseHemorrhoidsIBSHepatitis A, B or CAbdominal PainPassing GasDiverticulitisWeight Loss Intake FormPage 5 of 8
GENITO-URINARY TRACTDo you have any of the following concerns? (Check all that apply.)Kidney DiseasePainful UrinationFrequent UTIKidney StonesImpaired UrinationBlood in UrineFrequent UrinationFrequent Urination at NightHeavy FlowFEMALE REPRODUCTIVE / BREASTSDo you have any of the following concerns? (Check all that apply.)Irregular CyclesBreast Lumps/ TendernessDifficulty ConceivingVaginal DischargePremenstrual ProblemsBleeding Between CyclesMenopausal SymptomsClottingHeavy FlowNipple DischargePainful PeriodsMALE REPRODUCTIVEDo you have any of the following concerns? (Check all that apply.)Erectile DysfunctionProstate ProblemsTesticular Pain/SwellingPenile DischargeMUSCULOSKELETALDo you have any of the following concerns? (Check all that apply.)Neck/ShoulderMuscle Spasms/CrampsArm PainUpper Back PainLower Back PainLower Back PainLeg PainJoint PainNEUROLOGICDo you have any of the following concerns? (Check all that Loss of BalanceSeizures/EpilepsyENDOCRINEDo you have any of the following concerns? (Check all that Night SweatsFeeling Hot or ColdWeight Loss Intake FormPage 6 of 8
LIFESTYLEDo you typically eat at least three meals per day? Yes NoIf “No” why not?Describe your exercise routineDescribe your spiritual practiceHow many hours per night do you sleep? Do you wake rested? Yes NoLevel of education completed: High SchoolBachelorsMastersDoctorateOtherOccupation: Employer: Hours/Week:Do you enjoy work? Yes NoWhy or Why Not?In the past or present, have you: used nicotine? Yes NoIf “Yes” what form?Amount Frequency used alcohol? Yes NoIf “Yes” what form?Amount Frequency used recreational drugs? Yes NoIf “Yes” what form?Amount FrequencyHave you experienced any major traumas? Yes NoIf “Yes” please explain:How many glasses of non-caffeinated, non-carbonated beverages do you drink per day?List your interests and hobbiesWeight Loss Intake FormPage 7 of 8
I (patient name) acknowledge and understand that:1) Aleksandr Benji FNP and Aesthetic Solutions NY is NOT my primary Medical Doctor;2) All medical decisions regarding any current or future health conditions should be addressed by myprimary care physician;3) Aesthetic Solutions NY serves as only a resource for general well-being and preventive medicine anddoes NOT treat any existing illness;4) All supplied information is accurate and forthcoming;5) I have informed my primary care physician about services I am to receive at Aesthetic Solutions NYand he/she has no objections to such services.6) I have not been rushed into making any decisions and I have had ample opportunities to ask AleksandrBenji FNP and my primary care physician questions prior to receiving any treatment.7) I acknowledge that Aleksandr Benji FNP/ Aesthetic Solutions NY does not provide any promises orguarantees that the treatments I am to receive will be effective in helping to improve my current healthconditions and that in coming to Aesthetic Solutions NY, I had previously made a decision independent ofAesthetic Solutions NY to try the services offered at Aesthetic Solutions NY.8) I understand that there are NO REFUNDS and state that I can afford the services I am seeking and that Ihave not been made any promises as to the results or effectiveness of such services/treatments.PATIENT SIGNATUREDATEPRINT NAMEWeight Loss Intake FormPage 8 of 8
Weight Loss Intake Form Page 1 of 8 Aleksandr Benji FNP 98-71 Queens Blvd, Rego Park NY 11374 646-301-4000 Weight Loss Intake Form . All medical decisions regarding any current or future health conditions should be addressed by my primary care physician; 3) Aesthetic Solutions NY serves as only a resource for general well-being and preventive .
