|
current weight
|
|
|
Weight as a child
• • •
|
|
|
Weight at end of high school (lbs.)
|
Comments.
|
|
At heaviest weight?
|
|
|
Has weight increased gradually over the years?
|
|
|
Start gaining weight at the age
|
Triggering event
|
|
Maximum weight
|
in what year
|
|
Weight Watchers
|
Comments
|
|
Jenny Craig
|
Comments
|
|
weight loss attempts?
|
Past diets or programs
• • •
|
|
Largest weight loss
|
with which program?
|
|
Weight loss/appetite suppressant
|
Comments.
|
|
maximum pounds lost after surgery
|
Weight gained
|
|
Patient struggles with
• • •
|
Comment
|
|
|
|
|
Patient denies ever
• • •
|
Comment
|
|
Patient admits to
• • •
|
Comment
|
|
|
|
|
History of bulimia, anorexia
|
Comment
|
|
Goal Weight.
|
|
