Download How to Eat - The Fat Nutritionist

Learn to Eat
Application Form
Name
Age
Time Zone
Phone
Occupation
Home Address
City
Province/State
Postal Code
Eating/Dieting
1. What is there about the way you eat or your relationship with food that you’d like to change or
control?
2. How often do you compulsively or binge eat? (Select one.)
Never
Seldom
Monthly
Weekly
Almost daily
Daily
3. How much of the time do you now diet? (Select one.)
Never
Rarely
Sometimes
Often
Almost always
Always
4. How often do you starve yourself or try to go without eating? (Select one.)
Never
Rarely
Sometimes
Often
Almost always
Always
5. When did you first start dieting?
6. What did you weigh when you first started dieting?
7. What got you started dieting?
8. What, if any, relationship do you see between your dieting and binge eating?
More than once daily
Weight
1. How would you describe your present weight? (Select one.)
Very overweight
Moderately overweight
About average
Moderately underweight
Very underweight
2. How satisfied are you with the way you look at your present weight? (Select one.)
Completely satisfied
Moderately satisfied
3. What is your present weight?
Neutral
Moderately dissatisfied
Very dissatisfied
Your height?
4. What weight do you seem to maintain if you don’t diet?
5. At what weight do you think you would be most satisfied?
6. What were you maximum and minimum weights as an adult and at what age(s) did you weigh these
amounts?
Maximum:
Age:
Minimum:
Age:
A number of ways to lose weight are listed below. Please indicate when you have used which methods.
Methods:
TOPS, self help
Weight loss
businesses
Shots and pills
Medically
supervised diet
Unsupervised
diet
Not eating
Psychotherapy
Hypnosis
Other
Ages used
Number of
times used
Maximum
weight lost
Comments
Approximate
cost
Weight History
Using personal records, medical records, or just your memory, please record your weight for every year
from birth to present. Don’t worry if there are gaps – just fill in what you can.
Birth Weight:
Age:
Weight:
Age:
Weight:
Age:
Weight:
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Age:
Weight:
Family
1. When you were growing up, what were your parents’ concerns about your eating? (Select one.)
Finicky
Ate too much
Ate too little
Too many snacks
Mealtime behavior
Table manners
Other
Avoided some foods
2. Please elaborate.
3. Are your parents still concerned/involved with your weight?
Yes
No
4. When you were growing up, how concerned were your parents with their eating, weight or fitness?
(Select one.)
None
Very little
Moderate
Quite a bit
Considerable
5. Please describe your parents’ eating attitudes and behaviors.
Exercise
1. How frequently do you now exercise? (i.e. daily, monthly, etc.)
2. What do you do for exercise?
3. How hard do you exercise? (Select one.)
Not hard at all
1
2
3
4
Moderately
5
6
7
8
4. What is the major reason you exercise? (i.e. fun, weight loss, fitness, etc.)
Goals
What would you like to gain from this treatment?
9
Very hard
10