Jersey Medical Weight Loss Center
Pediatric Weight Loss Questionnaire
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Medications
*
Rows
Name of Medications & Strength
How many times
Reason for taking medications
1
2
3
4
Allergies
*
Rows
Yes
No
Food
Medications
Latex
Others
If yes explain
Medical History:
*
Rows
Yes
No
1. Diabetes
2. Hypertension
3. High Cholesterol
4. Sleep Apnea
5. Heart Murmur
6. Anemia
7. Metal Implants
8. Cancer
9. Developmental Problem
10. Congenital Disease
11. ADD/ADHD
12. Other medical conditions
Other medical conditions, explain
Family Health History
*
Rows
Yes
No
Relatives
Thyroid cancer
Other cancers
Heart attack/ Stroke
Hypertension
Obesity/overweight
Other medical disease
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/Rarely
Sometimes
Often
Almost Always
7. How do you describe your sleep quality?
*
Excellent
Good
Fair
Poor
8. How many hours of sleep do you get every night?
*
7-9 hours
5-7 hours
less than 5 hours
9. How many hours/week do you spend on exercise/physical activity?
*
No Time
Less than 2 Hours
2-4 Hours
More than 4 Hours
10. Do you have poor eating habits, including fast eating, overeating, mindless snacking and poor food choices?
*
Never/ Rarely
Sometimes
often
Almost Always
11. Do you have difficulty resisting food temptations at social occasions and recreational setting?
*
Never/ Rarely
Sometimes
Often
Almost Always
12. In a typical week, how many meals do you eat at a fast food restaurants?
*
0-1
2-3
4-5
more than 5
13. Do you feel anxious?
*
Never/ Rarely
Sometimes
Often
Almost Always
14. Do you tend to reach for food when you are happy, bored, sad, or stressed?
*
Yes
No
15. Do you feel depressed?
*
Never
Sometimes
Often
Almost 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/ Rarely
Sometimes
Often
Almost Often
18. Have you tried any commercial or medical weight loss program before?
*
Yes
No
If yes explain
19. Have you ever tried any weight loss medications?
*
Yes
No
20. How many times per week do you eat fast food?
*
None
2-3 times per week
more than 3 times per week
21. How many times per week do you eat on-the-go food?
*
None
2-3 times per week
more than 3 times per week
22. How many time 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 questions listed below:
*
Rows
Yes
No
1. Do you have headache?
2. Do you feel depressed?
3. Do you have any pain?
4. Do you suffer from frequent abdominal pain?
5. Are you having trouble walking?
6. Do you feel short of breath on exertion?
7. Do you get chest pain?
8. Do you have frequent diarrhea?
9.Are you frequently constipated?
10. Do you have back pain?
Signature of the parent/guardian
*
Name of the parent/guardian
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: