Weightloss Questionnaire 1

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WEIGHT LOSS QUESTIONNAIRE

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Patient Name: ______________________ Age: _______________ Date of Initial Consultation: _____________

Height: ____________________________ Current Weight: ______________ Goal Weight: ________________
How long have you been trying to lose weight? ___________________________________________________
What has been your heaviest weight? ___________________________________________________________
When were you that weight? (At what age?) _____________________________________________________
Have you ever stayed the same weight for 10 years of more? YES NO
Are any members of your household overweight? YES NO
If yes, please list the relationship and details _____________________________________________________
__________________________________________________________________________________________
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What was your motivation for wanting to lose weight? Check all that apply.
Don’t like the way I look Clothes don’t fit anymore
More energy Improve health
Better work opportunities Feel better
More mobility Want to wear smaller size
Look Better Perform better
Live longer Feel more confident socially
Reduce medications Look more attractive to my partner
Upcoming vacation Want to wear more stylish clothing
Attend an event Other: ______________________________
__________________________________________________________________________________________
What dietary problem areas apply to you? Check all that apply.
Skipping Meals
Craving carbohydrates Eating Foods too high in fat
Large portion sizes Eating too many meals in restaurants
Too much alcohol Eating for reasons other than hunger
Frequent snacking Eating before going to bed
Binging on food Making yourself vomit after meals
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What weight loss programs have you participated in?
PROGRAM/PLAN RESULTS? LENGTH OF PARTICIPATION?
WEIGHT WATCHERS
JENNY CRAIG
SLIM FAST
ATKINS
SOUTH BEACH
LA WEIGHT LOSS
NUTRISYSTEMS
LINDORA
OVEREATERS ANNONYMOUS
LIQUID DIETS (EG. OPTIFAST, JUICING)
DIET PILLS: MERIDIA, XENICAL
DIET PILLS: PHEN-FEN, REDUX
OTC DIET PILLS
OBESITY SURGERY
OTHER: ________________________________
Have you maintained any weight loss for up to one year on any of these programs? YES NO
What did you learn from these programs regarding your weight? _____________________________________
__________________________________________________________________________________________
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Why did these programs not meet your expectations? What did not work? ____________________________
__________________________________________________________________________________________
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Please answer the following questions on a scale of 1 – 5.
SCALE: LEAST 1 2 3 4 5 MOST
Your level of interest in losing weight is?

Are you ready for lifestyle changes to be part of your weight control program?
How much support can your family provide?
How much support can your friends provide?
How confident are you that you can lose weight this time?
How confident are you that you can keep the weight off this time?
FOOD ALLERGIES: ___________________________________________________________________________

FOOD DISLIKES: _____________________________________________________________________________
FOODS YOU CRAVE: _________________________________________________________________________
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HEALTH HABITS
On average, how many alcoholic beverages do you consume per week? _______________________________
How many caffeinated beverages do you consume per day? _________________________________________
Do you smoke? YES NO If yes, how often? ___________________________________________________
Average stress level: LOW MEDIUM HIGH why? ____________________________________________
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Please check the list below if you eat at the specified times.
DO YOU… TYPICAL FOODS CONSUMED DURING EACH SPECIFIED TIME
EAT BREAKFAST
EAT LUNCH
EAT DINNER
EAT BETWEEN MEALS
EAT AT NIGHT
EAT WHEN STRESSED
ACTIVITY LEVEL (check only one)

Inactive – No regular physical activity with a sit-down job
Light activity – No organized physical activity during leisure time
Moderate activity – Occasionally involved on activities such as weekend golf, tennis, jogging, swimming
or cycling
Heavy activity – Consistent lifting, stair climbing, heavy construction, or regular participation in jogging,
swimming, cycling or active sports at least 3 times per week.
Vigorous activity – Participation in extensive physical exercise for at least 60 minutes per session 4
times per week
BEHAVIOR STYLE (check only one)

You are always calm and easygoing
You are usually calm and easygoing
You are sometimes calm with frequent impatience
You are seldom calm and persistently driving for advancement
You are never calm and have overwhelming ambition
You are hard driving and can never relax
This information will assist us in identifying your particular problem areas. Thank you for your time and
patience in providing this information.
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___________________________________________________________________

WEIGHT LOSS QUESTIONNAIRE

Patient Name: ______________ Age: _ Date of Initial Consultation: _______

Your level of interest in losing weight is?

FOOD ALLERGIES: ___________________________________________________________________________

ACTIVITY LEVEL (check only one)

BEHAVIOR STYLE (check only one)

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