Pediatric Weight Loss Questionnaire

Pediatric Weight Loss Questionnaire

2186, Route 27, Suite 1B North Brunswick NJ 08902
Date

DayMonthYear
Date
Name

First NameLast Name

Medications*

	Name of Medications & Strength	How many times	Reason for taking medications
1
2
3
4

Allergies *

	Yes	No
Food
Medications
Latex
Others

If yes explain

Do you have:*

	Yes	No
1. Diabetes
2. Hypertension
3. High Cholesterol
4. Sleep Apnea
5. Arthritis
6. Heart Murmur
7. Anemia
8. Pacemaker
9. Metal Implants
10. Cancer
11. Weight Loss Surgery
12. Developmental Problem
13. Congenital Disease

Family Health History*

	Yes	No	Relatives
Cancer
Diabetes
Heart Disease/ Stroke
Hypertension
Mental Disease
Other

LIFESTYLE INFORMATION QUESTIONS
1.What is your goal weight?*
2.What is your heaviest weight in the last 2 year?*
3.What is your lowest weight in the last 2 years?*
4. What was your birth weight?*
5. Did you have any weight issues during infancy/ childhood?*
6. If you have your favorite food in the house, are you tempted to eat it even if you are not hungry?*

Never/RarelySometimesOftenAlmost Always
7. How do you describe your sleep quality?*

ExcellentGoodFairPoor
8. How many hours of sleep do you get every night?*

7-9 hours5-7 hoursless than 5 hours
9. How many hours/week do you spend on exercise/physical activity?*

No TimeLess than 2 Hours2-4 HoursMore than 4 Hours
10. Do you have poor eating habits, including fast eating, overeating, mindless snacking and poor food choices?*

Never/ RarelySometimesoftenAlmost Always
11. Do you have difficulty resisting food temptations at social occasions and recreational setting?*

Never/ RarelySometimesOftenAlmost Always
12. In a typical week, how many meals do you eat at a fast food restaurants?*

0-12-34-5more than 5
13. Do you feel anxious?*

Never/ RarelySometimesOftenAlmost Always
14. Do you tend to reach for food when you are happy, bored, sad, or stressed?*

YesNo
15. Do you feel depressed?*

NeverSometimesOftenAlmost always
16. How many hours per day do you spend on phone/computer/other electronic devices?*
17. In the past during dieting , have you ever lost the willpower to stay in track to reach your goals*

Never/ RarelySometimesOftenAlmost Often
18. Have you tried any commercial or medical weight loss program before?*

YesNo
If yes explain
19. Have you ever tried any weight loss medications?*

YesNo
20. How many times per week do you eat fast food?*

None2-3 times per weekmore than 3 times per week
21. How many times per week do you eat on-the-go food?*

None2-3 times per weekmore than 3 times per week
22. How many time per week do you eat home cooked food?*

None2-3 times per weekmore than 3 times per week
Review of Symptoms

Please check your answer to the questions 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 trouble walking?
7. Do you have any difficulty breathing
8.Do you have frequent chest pain?
9. Do you have frequent Diarrhea?
10.Are you frequently Constipated?
11. Do you. have frequent back pain?

Date

DayMonthYear
Date
Signature*

Clear
Should be Empty:

Pediatric Weight Loss Questionnaire

LIFESTYLE INFORMATION QUESTIONS

Review of Symptoms