<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>How does your weight affect your life and health? &nbsp;_________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;'><span style='font-size:15px;font-family:"Arial",sans-serif;'>___________________________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;'><span style='font-size:15px;font-family:"Arial",sans-serif;'>___________________________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Weight History</span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>When did you first notice that you were gaining weight?&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Childhood&nbsp; &nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Teens&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Adulthood&nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Pregnancy&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Menopause &nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Did you ever gain more than 20 pounds in less than 3 months? Y / N &nbsp; &nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>If so, when? &nbsp;_________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>How much did you weigh: one year ago? _____ &nbsp; Five years ago? _____ 10 years ago? _____&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Life events associated with weight gain (check all that apply):</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-.5in;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Marriage&nbsp; &nbsp; &nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Divorce&nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Pregnancy &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Abuse &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Illness&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;<br>&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Travel&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Injury&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Nightshift work &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Job change&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Quitting smoking&nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Alcohol&nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Drugs&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Medication (please list: ______________________________________________________________)<br>&nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Previous weight-loss programs (check all that apply): &nbsp; &nbsp; &nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Weight Watchers&nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Nutrisystem&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Jenny Craig&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;LA Weight Loss&nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Atkins &nbsp; &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;South Beach &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Zone diet&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Medifast &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Dash diet &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Paleo diet &nbsp; &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;HCG diet &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Mediterranean diet&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Ornish diet &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Other: _______________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>What was your maximum weight loss? ____________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>What are your greatest challenges with dieting? _____________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>___________________________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Have you ever taken medication to lose weight? (check all that apply): &nbsp; &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Phentermine (Adipex)&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Meridia&nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Xenecal/Alli&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Phen/Fen &nbsp; &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Phendimetrazine (Bontril)&nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Topamax&nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Saxenda&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Diethylpropion &nbsp; &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Bupropion (Wellbutrin) &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Belviq &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Qsymia &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Contrave</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Other (including supplements): __________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>What worked? _______________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>What didn&rsquo;t work? ____________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Why or why not? _____________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Nutritional History</span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>How often do you eat breakfast? _____ days per week at _____:_____ a.m.</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Number of times you eat per day: _____ What beverages do you drink? __________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Do you get up at night to eat? Y / N &nbsp; &nbsp; If so, how often? _____ times</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>List any food intolerances/restrictions: _____________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Food triggers (check all that apply):</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Stress&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Boredom&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Anger&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Insomnia &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Seeking reward&nbsp; &nbsp; &nbsp;&nbsp;<br>&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Parties&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Eating out&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Other: _______________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Food cravings:&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Sugar&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Chocolate&nbsp; &nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Starches&nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Salty&nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Fast food<br>&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;High fat&nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Large portions</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Favorite foods: _______________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'><span style="text-decoration: none;">&nbsp;</span></span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Medical History</span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Exercise type: ________________________________________________________________________&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Duration: _____ hours _____ minutes &nbsp; &nbsp; Number of times per week: _____</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Does anything limit you from exercising? ___________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>How many hours do you sleep per night? _____ &nbsp; &nbsp; Do you feel rested in the morning? _____</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Past medical history (check all that apply):</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Heart attack&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Angina&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Gallbladder stones&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Sleep apnea</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;High blood pressure&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Stroke&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Indigestion/reflux &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Thyroid</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;High cholesterol&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Diabetes&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Celiac disease&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Anxiety</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;High triglycerides&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Gout &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Pancreatitis&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Depression</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Infertility&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Arthritis &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Polycystic Ovarian Syndrome &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Bipolar<br>&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Glaucoma&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Cancer (type/s): ____________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Have you ever been diagnosed with an eating disorder? Y / N &nbsp; &nbsp; If yes, which one? _________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Past surgical history (check all that apply):</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Gastric bypass&nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Gastric banding&nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Gastric sleeve&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Gallbladder&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Heart bypass &nbsp; &nbsp;&nbsp;<br>&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Hysterectomy &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Other: _________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-13.5pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Medications (list all current medications, including over-the-counter medications, supplements, and herbs):</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>____________________ &nbsp;____________________ &nbsp;____________________ &nbsp;____________________ &nbsp;____________________ &nbsp;____________________ &nbsp;____________________ &nbsp;____________________ &nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Allergies: (Medications)________________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>(Food)______________________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Social History</span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-49.5pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Smoking:&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Never&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Current smoker (_____ packs/day)&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Past smoker (quit _____ years ago)</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Alcohol: &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Never&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Occasional&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Regularly (_____ drinks per day)</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Prior treatment for alcoholism? Y / N</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Drugs: &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Never &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Current&nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Past&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Type of drugs: ______________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Marijuana:&nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Never&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Current user (_____ times/day)</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'><span style="text-decoration: none;">&nbsp;</span></span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'><span style="text-decoration: none;">&nbsp;</span></span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'><span style="text-decoration: none;">&nbsp;</span></span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'><span style="text-decoration: none;">&nbsp;</span></span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'><span style="text-decoration: none;">&nbsp;</span></span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Family History</span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Obesity (check all that apply):&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Mother&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Father&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Sister&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Brother &nbsp; &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:1.5in;text-indent:.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Daughter&nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Son &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Diabetes (check all that apply): &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Mother &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Father &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Sister &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Brother &nbsp; &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:1.5in;text-indent:.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Daughter&nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Son</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-27.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Other (check all that apply): &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;High blood pressure &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Heart disease&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;High cholesterol &nbsp; &nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;High triglycerides&nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Stroke&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Thyroid problems&nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Anxiety&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Depression &nbsp; &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Bipolar disorder&nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Alcoholism&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Cancer (type/s): _______________________________________ Other: _______________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Gynecologic History</span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Age periods started? _____ &nbsp; &nbsp; Age periods ended _____ &nbsp;&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Periods are: &nbsp; &nbsp; Regular / Irregular &nbsp; &nbsp; Heavy / Normal / Light</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Number of pregnancies: _____ &nbsp; &nbsp; Number of children: _____</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Age of first pregnancy: _____ &nbsp; &nbsp; Age of last pregnancy: _____</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'><span style="text-decoration: none;">&nbsp;</span></span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><u><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>System Review&nbsp;</span></u></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>(Check all that apply)</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Recent weight loss more than 10 pounds</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Recent weight gain more than 10 pounds</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Acne&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Skin rash&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Cough</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Snoring&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Shortness of breath&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Chest pain</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Difficulty breathing when flat&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Fainting/Blacking out&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Palpitations</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Swelling ankles/extremities&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Abdominal pain&nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Bloating</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Constipation&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Diarrhea&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Food intolerance</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Dysphagia/difficulty swallowing&nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Indigestion&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Nausea/vomiting</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Increased appetite&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Decreased appetite&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Heartburn</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Gas and bloating&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Urinary frequency/urgency&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Slow urine flow</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Nighttime urination&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Blood in stools&nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Back pain (upper)</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Back pain (lower)&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Joint pain&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Muscle aches/pain</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Dizziness&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Headaches&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Seizures</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Weakness/low energy&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Anxiety&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Depression</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Insomnia&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Memory loss&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Inability to concentrate</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Mood changes&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Nervousness&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Loss of interest</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Cold intolerance&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Excessive sweating&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Hair changes</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Heat intolerance&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Blood clots&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Fatigue/tiredness</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><strong><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>(Women only)</span></strong></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Absence of periods&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Hot flashes&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Change in bladder habits</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Abnormal/excessive menstruation&nbsp;</span><span style="font-size:15px;line-height:115%;font-family:Wingdings;">o</span><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;Facial hair</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>Comments: _________________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>______________________________________________________________________________________________________________________________________________________________________</span></p>
<p style='margin:0in;font-size:16px;font-family:"Times New Roman",serif;margin-top:0in;margin-right:-9.0pt;margin-bottom:.0001pt;margin-left:-.5in;line-height:115%;'><span style='font-size:15px;line-height:115%;font-family:"Arial",sans-serif;'>&nbsp;</span></p>
