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PATIENT INFO
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Why do you want to lose weight?
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How Much weight would you like to lose?
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How often do you think about losing weight?
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Is this the heaviest you've ever been? If No what was your highest Weight
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What is your Highest Weight?
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When were you last at your Goal Weight (lbs.)
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Were you overweight as a child
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What diets have you tried?
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Other weight loss methods not listed that you have ? What did you like or dislike about each?
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I snack 2 or More times a day
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I rarely Plan Meals
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I skip 1 or More Meals a day
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Reasons to skip meals or overeat
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How often do you dine out?
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Favorite/ Most Frequent Resturant's you Dine at?
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Where do you eat your meals?
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You feel your appetite is
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Eating Pace
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How do you feel when you eat?
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After eating you feel
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Do you exercise?
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How often do you exercise?
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What kind of exercise do you do?
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Other Physical Activities
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Has a Physician Recommended that you lose weight ?
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On a Scale of 1-10 (10 being the highest), how important is it for you to lose weight?
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Are you ready to commit to losing weight?
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