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current weight
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Weight as a child
• • •
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Weight at end of high school (lbs.)
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Comments.
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At heaviest weight?
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Has weight increased gradually over the years?
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Start gaining weight at the age
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Triggering event
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Maximum weight
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in what year
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Lowest adult weight
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in what year
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Weight loss/appetite suppressant
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Comments
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weight loss attempts?
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with which program?
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Bariatric Surgery
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Type of Surgery
• • •
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Year of Surgery
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Surgery Center
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Maximum pounds lost after surgery
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Weight gained post surgery
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Patient struggles with
• • •
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Comment
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Patient denies ever
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Comment
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Patient admits to
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Comment
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BED Screener-7
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1. During the last 3 months, did you have any episodes of excessive overeating?
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NOTE: IF YOU ANSWERED “NO” TO QUESTION 1, YOU MAY STOP. THE REMAINING QUESTIONS DO NOT APPLY TO YOU.
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2. Do you feel distressed about your episodes of excessive overeating?
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Within the past 3 months…
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3. During your episodes of excessive overeating, how often did you feel like you had no control over your eating?
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4. During your episodes of excessive overeating, how often did you continue eating even though you were not hungry?
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5. During your episodes of excessive overeating, how often were you embarrassed by how much you ate?
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6. During your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterward?
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7. During the last 3 months, how often did you make yourself vomit as a means to control your weight or shape?
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Answers “YES” to question 2 and checks Sometimes/often/Always for all questions 3 -7, follow-up discussion should be considered
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History of bulimia, anorexia
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Goal Weight.
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Food Allergies/Aversions
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