Jersey Medical Weight Loss Center
Adult Weight Loss Questionnaire
Name
*
First Name
Middle Name
Last Name
Medications
*
Rows
Name of Medication and strength
How many times
Reason for taking Medications
1
2
3
4
5
Allergies
*
Rows
Yes
No
Food
Medications
Latex
Others
If yes, explain
Past Medical/Surgical History
*
Rows
Yes
No
1. Diabetes
2. Hypertension
3. High Cholesterol
4. Sleep Apnea
5. Weight Loss Surgery
6. Heart murmur
7. Pacemaker
8. Metal Implants (rods,pins, screws etc)If you have metal Implant, you will need clearance as well as a signed waiver to step on the Body Composition Analysis (BCA) scale
9. Thyroid Cancer
10. Any other type of cancer
11.Major Depression
12. Anxiety disorder
13. Heart attack
14. Heart failure
15. Stroke
16. Other medical conditions
Others medical conditions, explain
Family Health History
*
Rows
Yes
No
Relatives
Cancer
Diabetes
Heart Disease
Hypertension
Stroke
Other
Lifestyle Infomation Questions
1. If you have your favorite food in the house, are you tempted to eat it even if you are not hungry?
Never/ Rarely
Sometimes
Often
Almost Always
2. Do you snore loudly?
Yes
No
3. Do you feel sleepy during the daytime?
Yes
No
3. In past during dieting, have you ever lost the willpower to stay in track to reach your goals
Never / Rarely
Sometimes
Often
Almost Often
4. How many hours/ week do you spend exercising?
No Time
Less then 2 Hours
2-4 Hours
More than 4 Hours
5. Do you have poor eating habits, including fast eating, overeating, mindless snacking and poor food choices
Never/ Rarely
Sometimes
Often
Almost Always
6. Do you have great difficulty resisting food temptations at social occasions and recreational settings
Never/ Rarely
Sometimes
Often
Almost Always
7. In a typical week, how many meals do you eat at fast food resturants?
0-1
2-3
4-5
More than 5
8. Do you feel that you have a high level of stress in your life?
Never/ Rarely
Sometimes
Often
Almost Always
9. Do you tend to reach for food when you are happy, bored, sad, or stressed
Strongly Disagree
Disagree
Agree
Strongly Agree
10. Do you indulge in night time eating or snacking?
No
Yes
11. what is your goal weight?
*
12. What is your heaviest weight within the last past 5 years?
*
13.What is your lowest weight in the past 5 years?
*
14. Have you tried any commercial or medical weight loss program before?
Yes
No
If yes explain
15. Have you undergone any weight loss surgery or procedure?
Yes
No
If yes explain
16. Have you tried any weight loss medicines?
Yes
No
If yes explain
18.How many times per week do you eat on-the-go food?
None
2-3 times per week
more than 3 times per week
19.How many times per week do you eat home cooked food?
None
2-3 times per week
more than 3 times per week
Review of Symptoms
Please check your answer to the question listed below:
*
Rows
YES
NO
1. Do you get frequent headaches?
2. Do you feel depressed?
3. Do you have joint pains?
4. Do you suffer from frequent abdominal pain?
5. Are you having any trouble walking?
6. Do you feel short of breath on exertion ?
7. Do you get chest pains ?
8. Do you get frequent heart burn?
9. Do you have back pain?
10. Do you feel anxious?
11. Do you suffer from insomnia?
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Month
-
Day
Year
Date
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