Page 1 of 5 DR. WILLIAM ROMERO PATIENT’S NAME:

Dear Prospective Patient,

Thank you for considering my services for your health needs.

Please:

1.  Fill in your answers in the boxes beside or under the question. Some answers are pre-filled as default answers.

2.  Save the document as “Your last name, Your first name”, for example: Romero, William

3.  E-mail it to as an attachment. To do this, click on the “Attach File” button. AOL has it on the lower left corner of the e-mail window. This will take you to your file directory. Look for the file you saved and click on it.

4.  Don’t worry about questions you do not understand. We will go over the questions when you come.

5.  Avoid wearing stockings when you come for your initial visit because I need access to your right foot for the Body Composition Analysis. Do not put lotion on your right hand and right foot.

6.  At the end of this questionnaire are directions to the office. Select the page and print it if necessary.

7.  I will see you soon.

Take care,

Dr. Romero

METAMORPH
Center of Medical Weight Management
www.metamorphcenter.com 631-858-0500 / WILLIAM H. E. ROMERO, MD
Nutritional Medicine
103 Majestic Drive, Suite 100
Dix Hills, NY 11746

GENERAL INFORMATION

Date: / Name / DOB / Address
Leave / Last Name, First Name / Write address here
Sex: / F / Marital Status: / Age:
Home Phone: / 631- / Mobile Phone: / 631-
Work Phone: / 631- / Pager: / 631-
Occupation: / E-mail:
Referred by: / Ad seen in:

NUTRITION EVALUATION

Height (no shoes): / in / Desired weight: / lbs / Weight at 18 years: / in
Present weight: / lbs / Weight 1 year ago: / lbs / Highest weight ever: / lbs
When did you begin gaining excess weight? / Answer here
Why? / Answer here
Primary reasons to lose weight? To live longer
1. To improve my health status.
2. To look better and feel better.

PREVIOUS DIETS:

Type? / When? / Results?
Weight Watchers
Nutritionist

DOCTOR-PRESCRIBED APPETITE SUPPRESSANTS:

I have used appetite suppressants before and would like to use them again.
I have never used appetite suppressants before but would like to try them.
I definitely want to lose weight without appetite suppressants.
I have no opinion at this time.

EATING HABITS: (Please write in what you have been eating when you are not dieting.)

MEALS / WEEKDAYS / WEEKENDS
Breakfast
AM Snack / None usually / None usually
Lunch
PM Snack / None usually / None usually
Dinner
Night Snack / None usually / None usually

STRESS AND SLEEP:

How often do you eat a restaurant or a fast food each month? / 8-10 / times
Foods you crave most?
Do you eat more when stressed? / Yes
Foods you dislike?
What are your worst eating habits? / Eating after dinner
Do you wake at night? / Yes / If yes, why:
Do you snore? If yes, how bad?
Describe your sleep / 6-8 hours; remembers dreaming; feels rested in the morning
History of purging or use laxatives, etc. / Never

OTHER HABITS:

Do you: / Yes/No / What kind? / How much? / How often?
Drink alcohol?
Drink soda?
Drink coffee or tea?
Drink juices?
Use sugar?
Use sugar substitute?
Smoke?

ACTIVITIES:

How is your energy level? / State here whether you are tired and at what part of the day.
Exercise equipment at home? / Treadmill
Do you exercise? / If, yes, what kind?
How often?
Any physical restrictions? / For example, back or knee problems. If none, write None here.
Other sports activities?

MEDICAL HISTORY

CURRENT MEDICAL HISTORY:

Condition / Since / Medication
None

PAST MEDICAL HISTORY:

Condition / When / Medication / Resolved
None

HOSPITALIZATION OR SURGICAL HISTORY:

Condition / When / Surgery or Treatment
None

REVIEW OF SYSTEMS:

Condition / Yes/No / Condition / No / Yes / Condition / No / Yes
Alcoholism / No / Epilepsy / No / Psychiatric illness / No
Anemia / No / Fainting / No / Rheumatic fever / No
Arthritis / No / Frequent headaches / No / Shortness of breath / No
Asthma / No / Gallbladder disease / No / Stroke / No
Cancer / No / Gout / No / Suicide attempt / No
Chest pains / No / Hazardous activities / No / Swelling of feet / No
Chronic cough / No / Heart disease / No / Thyroid disease / No
Chronic diarrhea / No / High blood pressure / No / Ulcers / No
Constipation / No / Irregular heart beat / No / “Brain fog” / No
Deep vein thrombosis / No / Jaundice / No / Fatigue / No
Depression / No / Kidney disease / No / Falling or thin hair / No
Diabetes / No / Liver disease / No / Dry skin / No
Dizziness / No / Low back pain / No / Other illnesses / No
Drug addiction / No / Phlebitis / No / Yes
Notes:

ALLERGIES:

Food / No known allergies
Drugs / Not allergic to Penicillin ALLERGIC TO PENICILLIN
Others / No seasonal allergies

GYN HISTORY:

Age at onset: / 12 / yrs old / Date of last period:
Menopausal? / No / Any menopausal symptoms? / No
Hysterectomy? / No / Could you be pregnant? / No
Menstrual Flow: / Mild / Are your periods regular? / Yes
Duration of flow: / 4-5 / days / Are you taking birth control pills? / No
Fluid retention: / Mod / Are you using hormones? / No
Last GYN exam? / Any problems detected? / No
Facial Hair / No / If yes, what?
Acne
Infertility / No / No miscarriages
Last blood test: / Taken by:
Abnormal results: / None
Last EKG: / Taken by:
Reading: / Normal
Family Physician: / Dr. / Telephone: / 631-
Address:
Other Physician: / Dr. / Telephone: / 631-
Specialty:

FAMILY OBESITY AND MEDICAL HISTORY:

N= None S= Slight Obesity M= Moderate Obesity (50 pounds or more overweight) V= Very Obese (100 pounds +). Mark with a Capital X in the appropriate box. In the example, the father has Moderate Obesity.

RELATIVE / OBESITY / LIVING / DECEASED
N / S / M / V / State of Health / Cause of Death
Father / No DM2, No HTN, no thyroid problem
Mother / No DM2, No HTN, no thyroid problem
Brother(s)
Sister(s)
Spouse
Son(s)
Daughter(s)

OTHER FAMILY OBESITY AND MEDICAL HISTORY:

RELATIVE / SIGNIFICANT OBESITY OR MEDICAL CONDITION
Father’s / Father / No diabetes, no hypertension, no thyroid problems, no obesity
Mother / No diabetes, no hypertension, no thyroid problems, no obesity
Siblings / No diabetes, no hypertension, no thyroid problems, no obesity
Mother’s / Father / No diabetes, no hypertension, no thyroid problems, no obesity
Mother / No diabetes, no hypertension, no thyroid problems, no obesity
Siblings / No diabetes, no hypertension, no thyroid problems, no obesity

MEDICAL EVALUATION

Name: / Age: / Sex: / Date:
Present Illness: / Please state here why you want to see Dr. Romero. Include any condition that you think has contributed to your weight or to how you feel.

META MORPH CENTER, INC

103 MAJESTIC DRIVE, DIX HILLS 11746

631-858-0500

DIRECTIONS

EASTBOUND (Towards Riverhead):

Long Island Expressway

Exit 51, turn Left on Deer Park Avenue (Northbound), travel 2 miles until you pass under the Northern State Parkway. Stay on your LEFT at the fork in the road in front of Dix Hills Fire Department; take Left Road, Route 35 (To Huntington); bear Right to take the first available Right turn, Royal Lane, then turn Right on Majestic Drive. The office is the second house on the Left. Enter thru the side-door.

Northern State Parkway

Exit 42 North. Bear LEFT immediately as you exit on Deer Park Road and you will immediately come to the yellow flashing light in front of Dix Hills Fire Department; take the Left Road, Route 35 (To Huntington); then bear Right to take the first available Right turn, Royal Lane, then turn Right on Majestic Drive. The office is the second house on the Left. Enter thru the side-door.

Jericho Turnpike

Make a RIGHT on Deer Park Road (Wendy’s and Jeep on corners) and go about 1 mile. Make a LEFT on Royal Lane, and then turn Right on Majestic Drive. The office is the second house on the Left. Enter thru the side-door.

Main Street, Route 25A

Make a RIGHT on Park Avenue (Mobil gas station on corner) and go 6 miles south, passing Pulaski Road and Jericho Turnpike. When you see Pathmark on your left, you are exactly one mile away. Turn LEFT on Royal Lane, and then turn Right on Majestic Drive. The office is the second house on the Left. Enter thru the side-door.

WESTBOUND (Towards New York City):

Long Island Expressway

Exit 51, turn Right on Deer Park Avenue (Northbound) , travel 2 miles until you pass under the Northern State Parkway. Stay on your LEFT at the fork in the road in front of Dix Hills Fire Department; take Left Road, Route 35 (To Huntington); bear Right to take the first available Right turn, Royal Lane, then turn Right on Majestic Drive. The office is the second house on the Left. Enter thru the side-door.

Northern State Parkway

Exit 42 North. You come out on DeForest Road and come to Stop Sign by the Art League of Long Island. Cross the first road (Deer Park Road East), bearing very slight Left, and continue on Deer Park Road. Take the first available Right turn, Royal Lane, turn Right on Majestic Drive. The office is the second house on the Left. Enter thru the side-door.

Jericho Turnpike

When you see DSW Shoe Store and Elwood shopping center, bear Left on Deer Park Road East (Left of Kitchen Store). At the second traffic light, make a Right on Regency Lane, and then turn Left on Majestic Drive. The office will be on your Right. Enter thru the side-door.

Main Street, Route 25A

Make a LEFT on Park Avenue (Mobil gas station on corner) and go 6 miles south, passing Pulaski Road and Jericho Turnpike. When you see Pathmark on your left, you are exactly one mile away. Turn LEFT on Royal Lane, and then turn Right on Majestic Drive. The office is the second house on the Left. Enter thru the side-door.

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