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First name
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Middle name
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Last name
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Date of birth
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Age
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Gender
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How did you hear about us
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Weight History
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Height
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Weight
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Has a Physician Recommended that you lose weight ?
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Highest weight & when?
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Goal weight
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How Much weight would you like to lose?
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Why do you want to lose weight?
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Pattern of Weight Gain
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Possible reasons for gaining
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Were you overweight as a child
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At what age?
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Do you have or had any eating disorder:
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Please describe if yes:
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Body Measurements
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Chest
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Waist
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Hip
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Female Only Questions
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Are you Physiologically Female?
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Are you pregnant
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Pregnancy History
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Type of Birth
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Maternal Complications of pregnancy?
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Are you actively trying to get pregnant?
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Do you use OCP or IUD?
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Currently undergoing IVF?
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Have you ever undergone IVF?
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History of PCOS?
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Are you on any Hormone Replacement Therapy?
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Social History
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Do you drink alcohol
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If yes, how many drinks per week?
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Do you smoke or use tobacco?
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If yes, how many per day?
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Years used
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Any recreational drug use?
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If yes, which one(s):
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Social Determinants of Health
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Family Size
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Number of Kids
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Spousal Status
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Number of People living in house
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Highest Educational Level
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Work History
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History of Abuse
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Sleep History
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How many hours do you sleep on weeknights?
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How Many Hours Do you sleep on Weekends?
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Describe what you do 2 hours prior to Sleep
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Do you do Shift work?
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Shift work- Shifts and how many
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Do you use sleep devices?
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Do you use sleep medications or supplements
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Do you wake up at night?
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Anything else effecting sleep?
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Nutritional History
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How many meals do you eat a day?
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What type of meals do you normally eat?
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Where do you eat your meals?
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How often do you eat out?
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How long does it normally take for you to eat a meal?
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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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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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Food weakness: Please select all that apply:
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Select all that apply to your eating habits and current lifestyle
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Do you/have you counted calories?
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What diet(s) have you tried previously and how much weight loss?
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Have you ever joined a weight loss group?
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If so, which ones?
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Allergies to foods?
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If so, which ones? What happens?
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What weight loss medication(s) have you tried previously and how much weight loss?
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History of Eating Disorder
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What type of Eating disorder?
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Write down what you typically eat ( rst 2 to 3 items come to mind)
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Breakfast: Time of meal / Food eaten
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Snack: Time of meal / Food eaten
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Lunch: Time of meal / Food eaten
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Snack: Time of meal / Food eaten
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Dinner: Time of meal / Food eaten
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Snack: Time of meal / Food eaten
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Liquid intake
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Physical Activity History
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How often do you exercise?
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What type of activity, how long/day, how many days a week, intensity
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What have you tried in the past? Did/Do you enjoy it?
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What physical activity would you like to be able to do? (ie, Walk, run, squat, get up from chair easy, get off floor)
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Do you wear devices to help count step/activity
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Do you go to a gym or exercise in your home?
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If you stopped exercising, why did you stop?
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Medical History
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Problems Important to Weight Management
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CARDIOVASCULAR
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If other, specify
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RESPIRATORY
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If other, specify
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GASTROINTESTINAL
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If other, specify
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METABOLIC/ENDOCRINE
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If other, specify
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DERMATOLOGICAL
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If other, specify
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MUSCULOSKELETAL/PAIN
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If other, specify
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URINARY/REPRODUCTIVE
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If other, specify
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AUTOIMMUNE DISEASE
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If other, specify
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PLEASE LIST ANY OTHER HEALTH CONCERNS NOT LISTED ABOVE
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Medications and Supplements: List all
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Medication Name / Dose / Frequency / Reason
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Do you take steroid often (including ones prescribed by physician)
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Surgical History
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History of Bariatric History
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SURGICAL HISTORY Please list surgeries and year:
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Mental Health
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Mental Health Diagnosis
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What medications are you on for Mental Health?
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Did any of these medications increase weight gain?
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Family History
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Heart Disease: Mother / Father / Sister / Brother / Age
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High Blood Pressure: Mother / Father / Sister / Brother / Age
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Stroke: Mother / Father / Sister / Brother / Age
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Diabetes: Mother / Father / Sister / Brother / Age
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Overweight: Mother / Father / Sister / Brother / Age
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Autoimmune disease: Mother / Father / Sister / Brother / Age
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Medullary Thyroid Cancer: Mother / Father / Sister / Brother / Age
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Allergies
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Food
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Drug
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Labs within 6 months
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CBC/CMP- specifically Hbg, BUN/Cr/AST/ALT/Tbili. If done, Lipase.
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Lipid levels/Triglycerides/LDL/HDL/Total Cholesterol
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TSH/Free T4
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Hemoglobin A1C/ If diabetic-most recent Glucose
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