Jersey Medical Weight Loss/ Aparna Medical Associates
1527 Route 27, Suite 2100, Somerset, NJ 08873
Medical/Weight Loss Questionnaire
Name of Medication and strength
How many times
Reason for taking Medications
If yes, explain
Past Medical History
3. High Cholesterol
4. Sleep Apnea
6. Heart murmur
9. Any metal Implants
11.Weight Loss Surgery
Family Health History
Heart Disease/ Stroke
Lifestyle Infomation Questions
1. If I have my favorite foods in the house,I feel the food is calling me to have some in between meals
2. I snore loudly or I am very tired during waking hours or both
3. In past during dieting, I have lost the willpower to stay on track and reach my goals
Never / Rarely
4. Each week I spend the following amount of time exercising
Less then 2 Hours
More than 4 Hours
5. I have poor eating habits, including fast eating, overeating, mindless snacking and poor food choices
6. I have great difficulty resisting food temptations at social occasions and recreational settings
7. In a typical week, how many meals do you eat at fast food resturants?
More than 5
8. I feel that I have a high level of stress in my life
9. I tend to reach for food when I am happy, bored, sad, or stressed
10. what is your goal weight?
11. What is your heaviest weight?
12.What is your lowest weight in the past 5 years?
How many times per week do you eat from one of these Locations?
Prepare at Home
Review of Symptoms
Please Check your answer to the questions listed below:
1. Do you have headaches?
2. Do you feel Depressed?
3. Do you have trouble swallowing?
4. Do you have any pain?
5. Do you suffer from frequent abdominal pain?
6. Are you having trouble walking?
7. Do you have difficulty Breathing?
8. Do you have frequent Chest pain?
9. Do you have frequent Diarrhea?
10. Are you frequently Constipated?
11. Do you have frequently Back pain?
Should be Empty: