Supervised Weight Loss Attempts Please check all of the weight loss efforts you have tried – Home Gym Equipment LA Weight Loss Atkins Diet Acupuncture Gym Membership Nutri System Mayo Clinic Diet Diet Pills from MD Health Spa Psychological Counseling Richard Simons Diet Shots from MD Calorie Counting Supervised Calorie Scarsdale Diet Diet Center High Protein Counting Sugar Busters Craig Low Carb T.O.P.S. Slim Fast Overeaters Anonymous Low Fat Weight Watchers Beach Diet Optifast / Medifast Hypnosis Harris Fast Check Each Medication you have tried: Redux Acutrim OTC Fastin Metabolife OTC Tenuate Adipex Herbal Remedies OTC Phentermine Trimspa OTC Amphetamines Ionamin Pondimin Xenical Dexatrim OTC Meridia Phen fen Duration: Zenadrine OTC Level of Activity: Activity: Duration: Frequency: Limitations: Shortness of breath/pain Aerobics-Land Aerobics-Water Biking Organized Exercise Stairs Swimming Walking Do you use any of these walking aids daily? Cane Walker Wheelchair Motorized Cart / Last name: First: D.O.B.: Please use the scale below to describe to what degree the problems listed below have BOTHERED or DISTRESSED you during the past week, including today. Nervousness or shakiness inside Unwanted thoughts, words, or ideas that won’t leave your mind The idea that someone else can control your thoughts Feeling others are to for most of your troubles Trouble remembering things Feeling easily annoyed or irritated Feeling afraid in open spaces or in the street Thought of ending your life Hearing voices that other people do not hear Feeling that most people cannot be trusted Crying easily
Supervised Weight Loss Attempts – Please check all of the weight loss efforts you have tried Home Gym Equipment Gym Membership Health Spa Calorie Counting High Protein Low Carb Low Fat Hypnosis Atkins Diet Mayo Clinic Diet Richard Simons Scarsdale Diet Sugar Busters Slim Fast Beach Diet Acupuncture Diet Pills from MD Diet Shots from MD Diet Center Craig Overeaters Anonymous Optifast / Medifast LA Weight Loss Nutri System Psychological Counseling Supervised Calorie Counting T.O.P.S. Weight Watchers Harris Fast Check Each Medication you have tried: Acutrim OTC Adipex Amphetamines Dexatrim OTC Fastin Herbal Remedies OTC Ionamin Meridia Metabolife OTC Phentermine Pondimin Phen fen Duration: Redux Tenuate Trimspa OTC Xenical Zenadrine OTC Level of Activity: Activity: Aerobics-Land Duration: Frequency: Limitations: Shortness of breath/pain Aerobics-Water Biking Organized Exercise Stairs Swimming Walking Do you use any of these walking aids daily? Cane Walker Wheelchair Motorized Cart / Last name: First: D.O.B.: Please use the scale below to describe to what degree the problems listed below have BOTHERED or DISTRESSED you during the past week, including today. Nervousness or shakiness inside Unwanted thoughts, words, or ideas that won’t leave your mind The idea that someone else can control your thoughts Feeling others are to for most of your troubles Trouble remembering things Feeling easily annoyed or irritated Feeling afraid in open spaces or in the street Thought of ending your life Hearing voices that other people do not hear Feeling that most people cannot be trusted Crying easily