Weight Loss Questionnaire

Jersey Medical Weight Loss/ Aparna Medical Associates

1527 Route 27, Suite 2100, Somerset, NJ 08873
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 History *

	Yes	No
1. Diabetes
2. Hypertension
3. High Cholesterol
4. Sleep Apnea
5. Arthritis
6. Heart murmur
7. Anemia
8. Pacemaker
9. Any metal Implants
10. Cancer
11.Weight Loss Surgery

Family Health History *

	Yes	No	Relatives
Cancer
Diabetes
Heart Disease/ Stroke
Hypertension
Mental Disease
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 have headache?
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 any 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?

Date

Month Day Year
Date
Signature *

Clear
Should be Empty:

Jersey Medical Weight Loss/ Aparna Medical Associates