Download Weight Management Questionnaire

Melissa DeVera, RD, cWC, CLT
Integrative Dietitian-Nutritionist
555 Soquel Ave, Suite 260, Santa Cruz, CA 95062
phone: 831-251-2315 fax: 831-427-0874 [email protected]
Today’s Date ________________
Name ___________________________ Age _______ Date of Birth ____/____/____
Phone – Day (____)_____________ Evening (____)_______________
Mobile (____)________________
Address__________________________________________________ Apt. # ______
City ___________________________ State _________
Zip Code_________________
Email address
_________________________________________________________________________
Occupation:__________________________________________________________________
If the patient is under the age of 18:
Name(s) of legal guardians
_______________________________________________________
Contact numbers if different from above
______________________________________________
Who may I thank for your referral?
________________________________________________________
Current Health Care Provider(s)
____________________________
____________________________
____________________________
Who will be your surgeon?______________________________________________________
Who do you authorize me to fax your nutrition consult to? Please provide me with fax
number:
________________________________________________________________________
Emergency Contact
Name ____________________________ Relationship ________________
Daytime contact number (____)_______________
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Weight Management Questionnaire
Height: _______ Weight:________
Where was this done? Home? MD office?
List all medications, including over the counter, and reason for taking them (use the back page if you run
out of room
MEDICATION
FOR THIS CONDITION
Please list your medical history such as depression, high blood pressure, diabetes, arthritis
Please list all of your supplements and bring them in to your appointment
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Are you seeing/ or have seen a therapist?
[ ] Yes [ ] No
Have you been treated for an eating disorder such as bulimia, Binge Eating Disorder or Compulsive
Eating? [ ] Yes ________________________________________
[ ] No
Weight History:
What was your weight: six months ago?_______
One year ago? _________
Five years ago? __________
What is your preferred or “best” weight?_________
Why? ______________________________________________________________________________
When did you last achieve this weight?_______________________________________________
Have you always been overweight?
[ ] Yes
[ ] No
If no, can you pinpoint any significant events in your life right before you gained weight?
_______________________________________________________________________________
_______________________________________________________________________________
What was your highest adult weight?
Age? ______
What was your lowest adult weight?
Age? ______
What is your usual weight or weight fluctuations?
What was your weight at 18?
Have you ever attempted to lose weight?
[ ] Yes
[ ] No
If yes, please describe the diets you have been on, including diet pills.
Diet name:
Month/year began:
month/year ended:
Pounds lost:
How long kept off:
Diet name:
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Month/year began:
month/year ended:
Pounds lost:
How long kept off:
Diet name:
Month/year began:
month/year ended:
Pounds lost:
How long kept off:
What are some reasons you are keeping a higher body weight?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Please list all lifestyle changes you have attempted in the past 6-12 months to improve your health.
________________________________________________________________________________
________________________________________________________________________________
Please state what changes you have adopted as lifestyle changes and are currently still doing.
________________________________________________________________________________
________________________________________________________________________________
Do you have a family history of obesity? [ ] Yes [ ] No
If yes, which relatives?
___________________________________________________________
Meal Information:
Number meals per day?
Number of snacks per day?
1
2
0
3
1
2
 3
 Graze throughout the day
Number of meals eaten outside the home or as take-out? ____________
Where?__________________________________________________________________________
Number of days a week that you eat breakfast ________
If you skip meals, which ones?_______________________________________________________
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If you skip, why do you skip? ________________________________________________________
Who does most of the shopping? _____________________________________________________
Who does most of the cooking? __________________________________________________________
Where do you shop for food? ___________________________________________________________
Do you eat while driving? [ ] Yes [ ] No
Do you eat while at your desk or on the computer? [ ] Yes [ ] No
Do you eat while watching TV? [ ] Yes [ ] No
What are your most challenging eating situations( examples: seeing food at work, going out to eat,
traveling for work) _________________________________________________________________
____________________________________________________________________________________
Do you consider yourself a slow or fast eater?_______________
About how long does it take for you to finish a meal?____________
Do you snack at night? [ ] Yes [ ] No
If so, what do you snack on?_____________________________________________________________
Does anyone live with you that influences how you eat? [ ] Yes [ ] No
If yes, how? _____________________________________________________________________
________________________________________________________________________________
List the fruits and vegetable you enjoy: ____________________________________________________
_______________________________________________________________________________________
How often do you eat fruit? __________ pieces or servings a day /________pieces or servings a week
How often do you eat a serving of vegetable (1/2cup cooked or raw or 1 cup of salad equals a serving)
__________ servings a day/ ___________servings a week
How often do you drink sugar-sweetened beverages or juice? _______ per day/ _______ per week
Types: __________________________________________________________________________________
How often do you eat sweets: candy, pastries, cookies, ice cream etc.? ________per day/ _______ per week
Types: __________________________________________________________________________________
How often do you eat fried foods such as chips, fried chicken, French fries, refried beans?
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__________________________________________________________________________________
What types of protein do you eat such as poultry, red meat, cheese, eggs, cottage cheese etc?
____________________________________________________________________________________
What types of fats / oils do you eat such as butter, olive oil, sour cream, avocado, salad dressing, nuts,
mayonnaise etc?
_______________________________________________________________________________________
What types of carbohydrates do you eat such as bread, cereal, tortillas, rice, crackers, bagels, pasta etc?
____________________________________________________________________________________
How many servings of calcium do you get a day? (A serving = 1 cup of milk, 1 cup yogurt, 1.5 oz cheese,
1 cup of calcium fortified almond milk, 1 cup of calcium fortified OJ) _______ servings per day
Smoking & Alcohol:
a.  Nonsmoker
 Quit smoking When? __________________
b. How much alcohol do you drink? _____ per night or __________ per week or _____ per month
and what do you drink:______________________________________________________________
Stress Management:
Please describe your stress level:
 Low
 Moderate
 High
List major stressful events in the past year, such as illness, death in the family, financial stress,
divorce, etc.)
What things do you relax or de-stress?
______________________________________________________________________________
______________________________________________________________________________
How many hours do you sleep at night?
Describe:______________________________________________________________________
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If you are doing some type of exercise now, what are you doing?
Activity ___________________________ days per week_________ Time in minutes_______
Activity ___________________________ days per week_________ Time in minutes_______
Three- Day Food Record
Please record what you eat and drink for three TYPICAL days, two weekdays and one weekend day.
Include time of day, beverages and foods in approximate amounts. Please be as specific as you can.
For example, instead of writing down salad, write down what you had in your salad and the type of
dressing. Include all meals, snacks and anything you grab to eat during the day. Thank you!
Date:__________________
Day of the Week:_____________
Time/ Food- Beverage
Amount
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Melissa DeVera RD, cWC, CLT
555 Soquel Ave, Suite 260, Santa Cruz, CA 95062
Fax: 831-427-0874 Phone: 831-251-2315
Notice of Privacy & Patient Acknowledgement
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
Federal privacy law permits health care providers and those that assist them to use certain types of
client health information without a client’s consent. The permitted uses of the information are for
providing treatment to the client (which might include disclosures between dietitian, physical therapist,
acupuncturist, chiropractor, naturopath and physician) for the purposes of collecting payment for
treatment from private insurers (such as submitting diagnostic information and test results to your
insurance company), or to a collection agency for non-payment. Health information may also be used
for certain health care operations.
Client health information may be used for other purposes only with the written consent of the client (or
client’s guardian or parent). It is the policy that I, Melissa DeVera, RD, cWC, CLT, will limit my use of
your health information to the purposes described above. Therefore, this is a notice to you of my policy
and not a request for permission to use your health information. By signing below you are merely
confirming that you have reviewed this document.
Federal law permits clients to examine their medical records once each calendar year at no cost to the
client. Clients may be charged for additional requests during the same calendar year. If a client believes
the medical records contain inaccurate information, the client is permitted to ask that the records be
corrected. The provider will investigate any claim of inaccuracy and make any corrections where
warranted. If you wish to examine your medical records in the possession of a physician, physical
therapist, acupuncturist, chiropractor, naturopath, or personal trainer, you must contact them directly. If
you wish to review your medical records in the possession of Melissa DeVera, RD, cWC, CLT, the
request must be in writing. You may make that request by writing to me, Melissa DeVera, RD, cWC,
CLT, at 555 Soquel Ave, Suite 260, Santa Cruz, CA 95062
ACKNOWLEDGEMENT OF RECIEPT OF PRIVACY PRACTICES
o I acknowledge reading a copy of the notice of privacy practices of Melissa DeVera, RD,
cWC, CLT
o I waive reading a copy of the notice of privacy practices of Melissa DeVera, RD, cWC,
CLT
Signature of Client / Guardian _________________________________ Date___________________
PERMISSION TO LEAVE MESSAGES
I waive the usual permissions and protections of HIPPA for the convenience of quick contact by
o Phone (list numbers) ______________________________________________
o Email (list address)
_____________________________________________
o Texting (list mobile number) _______________________________________________
PERMISSION TO SHARE YOUR INFORMATION WITH HELPER:
I waive the usual permissions and protections of HIPPA for the convenience of information sharing
with the following people who will be assisting
me:_______________________________________________________________________________
__________________________________________________________________________________
Signature of Client/ Guardian
Date
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is
to be considered as valid as the original
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