WEIGHT, HEALTH, AND LIFESTYLE QUESTIONNAIRE
All questions contained in this questionnaire are confidential and will become part of your medical record. All questions are optional.
Basic Personal Information
Today's Date
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Month
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Day
Year
Date
Date of Birth
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Month
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Day
Year
Date
Full Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please List Your Insurance Provider
Ethnicity (Check all that apply)
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American Indian
Asian
African American
Hispanic White
Other
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Continue to Weight History
Weight History
Have there been any circumstances or life events that have triggered weight gain for you?
Pregnancy
Job Change
Stress Boredom
Marriage
Divorce
Illness
Injury
Abuse
Alcohol
Nightshift Work
Travel
Quitting Smoking
New Medication
Other
Has your weight stayed relatively the same?
Please Select
Yes
Answer as many as you can:
Rows
Weight in lbs.
The Past 6 Months my weight was:
1 Year Ago my weight was:
2 Years Ago my weight was:
5 years Ago my weight was:
Your Highest Past Weight was:
Your Weight Around Age 20 was:
Have you lost weight with weight loss programs or diet plans in the past? If so, select from the list the program/method. (check all that apply):
Weight Watchers
Nutrisystem
Jenny Craig
LA Weight Loss
Atkins
Keto diet
South Beach
Zone diet
Medifast
Dash diet
Paleo diet
Mediterranean diet
Omish diet
Intermittent Fasting
Time restricted eating
Other
Weight Loss Prescription Medications
Have you ever used any prescription medications for weight loss? (check all that apply):
Phentermine (adipex)
Meridia
Xenecal/Ali
Phen/Fen
Phendimetrazine (Bontril)
Topamax
Saxenda
Diethylpropion
Bupropion (Wellbutin)
Belviq
Qsymia
Contrave
Wegovy
Other (Including Supplements)
Other Prescription Medication Use
Bariatric Surgery
Have you ever had bariatric surgery?
Please Select
Yes
No
If yes, please list the procedure(s) and year(s).
Are you currently interested in considering bariatric surgery?
Please Select
Yes
No
Have you ever consulted a surgeon regarding bariatric surgery?
Please Select
Yes
No
Back to Basic Personal Information
Continue to Diagnosed Conditions
Diagnosed Conditions
Have you ever been diagnosed with any of the following? (please check all that apply)
Hypertension (high blood pressure)
Thyroid disease
Chronic Kidney disease
Hyperlipidemia (high cholesterol)
Osteoarthritis
Autoimmune disorder
Diabetes (high blood sugar)
Back Pain
Pseudotumor cerebri
Prediabetes/ Insulin Resistance
Acid Reflux
Cushing's syndrome
Gestational Diabetes
Irritable Bowel syndrome
Infertility
Hernia
COPD/Emphysema
PCOS (Polycystic Ovarian Syndrome)
Gallstones
Asthma
Metabolic syndrome
Depression
Lymphedema
Fatty Liver disease
Anxiety Sleep disorder
Cirrhosis
Bipolar disorder
Sleep Apnea
Lymphedema
Eating disorder: Anemia
Lipidema
Heart attack
Coronary artery disease
Abnormal heart rhythm
Heart murmur
Stroke
Heart valve disease
Heart failur
Seizures Glaucoma
Pacemaker implanted
Pancreatitis
MEN Type 2
Primary Pulmonary Hypertension
Medullar Thyroid Cancer
Kidney Stones
Hyperthyroidism
Cancer
Vitamin deficiency
Other Medical Condition
Other Diagnosed Condition (Cancer, Vitamin Deficiency or Other)
Back to Weight History
Continue to Medication History
Medications
List all the medications you currently take (including vitamins and supplements). Please indicate the dosage and frequency (number of times per day) of each medication.
Rows
Medication Name
Dosage
Frequency Taken (times per day)
1
2
3
4
Medication Allergies
Please list any medication allergies and your response:
Rows
Medication Name
Response
1
2
3
4
Back to Diagnosed Conditions
Additional Information
Additional Information
Please use this space to provide any additional information that you think is important to understanding you or your weight problem, as well as the goals you seek.
Submit
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