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
*
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