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