Jersey Medical Weight Loss/ Aparna Medical Associates
2186, Route 27, Suite 1B North Brunswick NJ 08902
Weight Loss Questionnaire
Name
First Name
Middle Name
Last Name
Medications
*
Name of Medication and strength
How many times
Reason for taking Medications
1
2
3
4
5
Allergies
*
Yes
No
Food
Medications
Latex
Others
If yes, explain
Past Medical/Surgical History
*
Yes
No
1. Diabetes
2. Hypertension
3. High Cholesterol
4. Sleep Apnea
5. Arthritis
6. Heart murmur
7. Pacemaker
8. Any metal Implants
9. Cancer
10.Weight Loss Surgery
11.Major Depression
12. Anxiety disorder
13. Heart attack
14. Heart failure
15. Stroke
Others
Family Health History
*
Yes
No
Relatives
Cancer
Diabetes
Heart Disease/ Stroke
Hypertension
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. what is your goal weight?
*
11. What is your heaviest weight within the last past 5 years?
*
12.What is your lowest weight in the past 5 years?
*
13. Have you tried any commercial or medical weight loss program before?
Yes
No
If yes explain
14. Have you tried any weight loss medicines?
Yes
No
If yes explain
15.How many times per week do you eat fast food?
None
2-3 times per week
more than 3 times per week
16.How many times per week do you eat on-the-go food?
None
2-3 times per week
more than 3 times per week
17.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:
*
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?
Date
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Month
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Day
Year
Date
Signature
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