Pediatric Weight Loss Questionnaire

Jersey Medical Weight Loss Center
Pediatric Weight Loss Questionnaire
Date*

MonthDayYear
Date
Name*

First NameLast 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/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:*

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 NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Jersey Medical Weight Loss Center

LIFESTYLE INFORMATION QUESTIONS

Review of Symptoms