Download Weight Loss Program Questionare

Weight loss Profile
Dietary consultation involves a weight loss profile. Its purpose is not to establish a diagnosis, but rather to
determine a patient’s health status in order to guide his or her weight-loss plan. A patient may be advised
to seek medical advice based on his or her weight loss profile.
General
Name ___________________________________ Age: ___________ DOB_________
How did you hear about our program? ______________________________________
Job/Occupation:________________________ Who is your doctor? ___________________
Email Address_____________________________________
Do you have any of the following:
____ High blood pressure
____ Heart disease
____ High cholesterol
____ Thyroid disease
____ Low Energy
____ Anxiety/Stress
____ Prostate problems
____ Yeast Infections
____ Kidney stones
____Ulcer
____Glaucoma
____ Kidney disease
____ Lactose intolerance
____ Celiac disease
____ Colon problems
____ Constipation
____ Diverticulosis
____ Cramps (PMS)
____ Food Cravings
____ Sleep Apnea
____TIA’s (ministrokes)
____ Liver disease
____ Illicit Drug Use
____ Gout
____ Acid reflux
____ Trouble sleeping
____ Joint problems/aches
____ Bloating
____ Eating Disorders (Bulimia/ Anorexia)
____ Juvenile Diabetes/ Pre-Diabetes/ Diabetes
____Depression
____Pacemaker/ Defibrillator
Please list any other medical problems you have:
_______________________________
____________________________
_______________________________
____________________________
Are you pregnant? ____ Yes
____ No
Do you smoke? ____ No ____ Yes (How much, and how often?________________________)
Do you drink alcohol? ____ No ____ Yes (How much, and how often? _________________
_________________)
Do you take a multivitamin? ____Yes ____
Do you take Fish Oil? ___ Yes ___No
Do you take any medications (including prescriptions, over-the-counter, vitamins)?
__________________________________
_________________________________
__________________________________
_________________________________
Are you allergic to any medicines or foods? ________________________________________
_______________________ ________________________ ____________________________
Have you ever had your metabolism tested? ____No ____Yes (By who?________________)
Do you exercise? ____ Yes ____ No
-If yes, how many days/week_______ Minutes each day_________, and what is your
exercise of choice____________________________________________?
What is your goal:
____ Weight loss ____ Muscle size ____ Fitness ____ Flexibility ___ Health
Please name your 2 favorite foods: __________________________________________
__________________________________________
What types of food do you usually crave? ________________________
________________________
Do you think that eating food gives you a lot of pleasure? ____ Yes ____ No
Do you look for food when you are sad or stressed? ____ Yes ____ No ____ Sometimes
Do you ever find yourself eating after you feel full/satisfied?
____Always ____Often
____ Rarely ____ Never
Have you ever tried to lose weight before? ____ Yes ____ No
If yes, please tell us how: ______________________________________________________
If yes, please specify which diet and why you think it didn’t work for you (ex) too
complicated, too much cooking involved, etc.): ____________________________________
____________________________________________________________________________
Have you had bariatric surgery (surgery for weight loss)? ____ Yes ____ No
What time do you usually eat:
Breakfast: _________
Dinner:_________
Lunch:__________
Snacks:__________
Please give an example of a typical breakfast, lunch, dinner and snack.
(Please be specific, ex. 2 slices of toast with butter, 8 oz. O.J., 8 oz. coffee with 2 tablespoons of sugar and cream)
A typical breakfast:
________________________________________________________________________
A typical lunch:
________________________________________________________________________
A typical dinner:
_________________________________________________________________________
A typical Dessert:
(Only if you have dessert after most meals)
_______________________________________________________________________
A typical snack:
________________________________________________________________________
Which one is your largest meal of the day? ___________________________________
Which meal(s) do you tend to skip? _________________________________________
Do you dine out, stop for fast food, or pizza? ___No ___Yes How often?__________
Do you want us to send progress reports to your doctor? ____ Yes
____ No
What is your current weight?___________lbs.
What was your highest weight?__________lbs.
What is your goal weight? ______________lbs.
When did you begin to gain weight?_______________________________________________
How long have you been overweight?______________________________________________
Please tell us the main reason(s) why you want to lose weight: _________________________
Any additional information you would like for us to know?
_____________________________________________________________________________________
No potential dieter is to be placed on a high protein protocol with a history of or current diagnosis
of the any following conditions without written consent from his/her primary care provider or
specialist monitoring this patient.
 History of cardio-vascular events: (i.e. heart attack, stroke, aneurysm, by-pass, stent
surgery, history of having cardiac arrhythmia including having a pace-maker)
 History of or current active cancer, including skin cancers
 Pregnant female (note from OB/GYN ONLY)
 Breast feeding female
 Severe Liver Disease
 Severe Kidney Disease
 Diagnosis or history of congestive heart failure (CHF)
 Patients currently on Lithium therapy
 Patients with a diagnosis of Parkinson’s Disease
I agree to consult with my primary care physician to guarantee the safety of the recommendations
made to me for weight management and exercise.
________________________________
Patient
Reviewed by Physician
__________________________________
Witness