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SECTION FOR PROFESSIONALS IN THE TREATMENT OF OBESITY AND OTHER EATING DISORDERS

Professional Bariatric History

Sample file to be used as a guide for professional in the treatment of obesity.

Part (III)

HEREDITARY AND FAMILY ANTECEDENTS
MATERNAL GRANDFATHER:  
MATERNAL GRANDMOTHER:  
 PATERNAL GRANDFATHER:  
PATERNAL GRANDMOHTHER:  
MATERNAL UNCLES:  
PATERNAL UNCLES:  
OTHER RELATIVES.:  
MOTHER:  
FATHER:  
BROTHERS/SISTERS:  
   

 

PERSONAL PATHOLOGICAL RECORD
Weight at birth:  
Height at birth:  
Growth development:  
Childhood diseases:  
Important diseases:  
Alergies:  
Surgical record:  
Gynecological record:  
Menarche:  
Beginning date of last menstruation:  
Menstrual cycle:  
Gestate:  
Due date:  
Abortion:  
Anovulatory method:  
Climateric/Menopause:  
Present medication:  
Reason:  
Dosage:  
Time:  
Reason:  
Dosage:  
Time:  
Reason:  
Dosage:  
Time:  

 

PHYSICAL EXPLORATION
Head:  
Neck:  
Thorax:  
Upper limbs:  
Lower limbs:  
Spine:  
Sense organs:  

 

VITAL SIGNS
Blood pressure:  
Hearth rate:  
Respiratory rate:  
Temperature:  

 

LABORATORY TESTS:

  

 

OTHER TESTS :
(if necessary):

  

 

Date and place:

  

 

NAME AND SIGNATURE OF PATIENT CONSENT:

FOLLOWING: THE IMPORTANT ROLE OF THE HEALTH PROFESSIONAL


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Dear visitor: The object of this web site is to inform and educate. Therefore, the information contained herein does not substitute professional medical attention.
If you have any doubt with respect to this information consult your personal doctor.

Medical supervision by Dr. Arieh Goldberg Kalik.
Bariatric physician, certified medical nutrition specialist. Certificate # 1010084

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