Jersey Medical Weight Loss/ Aparna Medical Associates
1527 Route 27, Suite 2100, Somerset, NJ 08873
Medical/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 I have my favorite foods in the house,I feel the food is calling me to have some in between meals
Never/ Rarely
Sometimes
Often
Almost Always
2. I snore loudly or I am very tired during waking hours or both
Never/ Rarely
Sometimes
Often
Almost Often
3. In past during dieting, I have lost the willpower to stay on track and reach my goals
Never / Rarely
Sometimes
Often
Almost Often
4. Each week I spend the following amount of time exercising
No Time
Less then 2 Hours
2-4 Hours
More than 4 Hours
5. I have poor eating habits, including fast eating, overeating, mindless snacking and poor food choices
Never/ Rarely
Sometimes
Often
Almost Always
6. I 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. I feel that I have a high level of stress in my life
Never/ Rarely
Sometimes
Often
Almost Always
9. I tend to reach for food when I am happy, bored, sad, or stressed
Strongly Disagree
Disagree
Agree
Strongly Agree
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
On-The-Go
Fast Food
Breakfast
Lunch
Snacks
Dinner
Total
Review of Symptoms
Please Check your answer to the questions listed below:
Yes
No
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?
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