Patient Questionnaire

The information requested in this questionnaire is very important. To give you the best care and to obtain insurance approval if applicable, please fill out as completely as possible. When complete, click on the yellow SUBMIT button. This will send your health information in a secure manner to Dr. Hansen.

In your own words, please describe your condition, how it affects your life, what makes any symptoms worse or better, and what testing has been performed:

Your name (first & last):         Today's date:

Past Medical History (Please check each item that you have experienced or affects you.)

No Active or Past Medical History Issues  
Diabetes   Heart Disease  
Congestive Heart Failure   Swollen Legs  
High Blood Pressure   Chronic Bronchitis  
Emphysema   Sleep Apnea  
Asthma   Acid Reflex  
Colon Cancer   Breast Cancer  
Prostate Cancer   Ovarian Cancer  

Additional information or other conditions not listed above:

Surgical History

No Previous Surgeries or Hospitalizations  
Tonsillectomy   Appendectomy 
Hysterectomy   Spleen Removed  
Ovaries removed   Cesarean Section  
Organ Transplant   Spinal Fusion  
Gall Bladder   Joint Replacement  
Part of Colon or Small Intestine Removed  
Hernia Repair   Details:
Additional information or other surgeries not listed above:

Family History
Click the box to make a selection and add details to the right

Condition Family Member Details
Coronary Artery Disease  
High Blood Pressure  

Social History
Explain quantities, quitting history, other info

Alcohol Consumption:      
Tobacco Consumption:      
Recreational Drugs:      
Occupation:       What is your work?
Marital Status:

Please click on any item or area that has been or is a concern to you or is a medical/health issue which you have dealt with:

  Weight Loss or Gain     Fever     Loss of Apetite     Fatigue  

  Rash     Itching     Breast Lump     Dry Skin 
  Breast Tenderness     Breast Swelling     Nipple Discharge     Pigmentation  

  Headaches     Dizziness     Lightheadedness  
  Tearing     Head Injury    Vision Change  
  Double Vision     Eye Pain    Nose Bleeding  
  Hoarse Voice     Bleeding Gums     Sinus Infection  
  Trouble Hearing     Thyroid Mass     Neck Stiffness, Pain, or Tenderness  

  Chest Pain     Palpitations     Shortness of Breath during exertion  
  Difficulty Breathing when lying down     Fainting     Swelling  
  Awakening at night w/difficulty breathing     Heart Murmurs 

  Pain with Breathing     Shortness of Breath     Wheezing     Cough  
  Coughing up Blood     Recurring Infections     Tuberculosis     Night Sweats  

  Loss of Apetite     Difficulty Swallowing     Stomach Ache after eating     Nausea and Vomiting  
  Vomiting Blood     Jaundice     Heartburn     Diarrhea  
  Abnormal Stools     Hemorrhoids     Constipation  

  Urgency     Frequency     Pain with Urination     Blood in Urine  
  Excessive Urine     Urinary Retention     Recurring Infections     Kidney Stones  
  Vaginal Discharge     Vaginal Bleeding     Enlarged Prostate  

  Seizures     Paralysis     Incoordination  
  Uncoordinated Movements     Numbness/Tingling     Loss of Memory  
  Sensory or Motor Disturbances     Tremor    Depression  
  Hallucinations     Suicidal Thoughts     Anxiety  

  Pain     Swelling     Night Cramps     Joint Pain  
  Weakness     Muscle Atrophy     Limited Range of Motion  

  Mini Strokes     Leg cramps when walking     Temporary Vision Loss  
  Strokes     Difficulty Speaking     Non-Healing Foot Sore  
  Weak or Numb on One Side     Pain in Calves when at Rest  

  Bleeding Tendency     Transfusions     Heat or Cold Intolerance     Anemia  


Type in any allergies to medications you have


Type in any medications you are currently taking

If you are a candidate for lap-band surgery or are condsidering this procedure, please complete the following sections of this form. Otherwise, click on this button:


Seminar Attendance Date:  

Dietary History
Approximate age when you first seriously dieted:  

List the diets and diet programs you have tried:
Program                           Date                           Duration                     Supervised?         Max Loss/Regained
Jenny Craig   Yes  
Nutri-System   Yes  
Weight Watchers   Yes  
OptiFast   Yes  
MediFast   Yes  
LA Weight Loss   Yes  
Fen/Phen/Redux   Yes  
Meridia   Yes  
Lindora   Yes  
T.O.P.S.   Yes  
Overeaters Anonymous   Yes  
Acupuncture   Yes  
Metabolife   Yes  
Atkins Diet   Yes  
List any other physician-supervised, self-directed exercising and/or documented weight loss attempts:

Your current weight:  
Your target body weight:  
Your lowest weight in the past 5 years:   Age at the time:  
Your highest weight in the past 5 years:   Age at the time:  


Thank you for taking the time to review your medical and health history


Dr. Darrin Hansen and team