Weight Regulation Intake Form

Thank you for choosing the Cooper Center for Metabolism. Please complete the form below.
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Gender *
Do you have a family history of diabetes? *
Did your mother have gestational diabetes when she was pregnant with you? *
Did your mother smoke when she was pregnant with you? *
Did your mother take the morning sickness medication DES during pregnancy or nursing? *
What was your approximate birth weight (pounds)? *
Was your birth early, late, or on-time? *
Were you breastfed as a newborn or infant? *
Have you had migraine headaches? *
Have you been prescribed prednisone, cortisone shots, or any other oral, injection, or inhaled steroids before? *
If you are female, have you been prescribed progesterone shots, pills or creams before?
Have you had "problematic satiety"? Is it or has it been difficult to sense being satisfied after meals and eating? *
 
If you are an adult female with biological children, have any of your children's birth weights been high or low? Choose all that apply:
If you are an adult female with biological children, have any of your children suffered from or experienced feeding issues in infancy?
If you are an adult female with biological children, did you ever have a diagnosis of gestational diabetes during any of your pregnancies?