Weight Management Patient History Questionnaire
The information requested below is very important. To give you the best care, we must have complete and honest answers. Please be thorough. Thank you
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please record current home values below. If you do not have a blood pressure cuff, use your last recorded vitals.
Height
Feet/Inches
Weight
Pounds
Blood Pressure
Heart Rate
WEIGHT HISTORY
Please estimate as closely as possible for all that applies.
Rows
Age
Weight
Lowest Weight in past five years
Highest Weight in past five years
Weight one year ago
Other
What is your Goal Weight?
Do you use a home scale?
Yes
No
How often do you weigh yourself?
Every day
Most days per week
Some days per week
Less than two days per week
Have you had bariatric surgery?
Yes
No
If No, are you interested in learning more about bariatric/weight loss surgery?
Yes
No
If Yes, which procedure and when?
LapBand
Gastric Bypass
Gastric Sleeve
If yes, Select the procedure date
-
Month
-
Day
Year
Date
What is motivating you to seek this type of intervention for weight control and/or loss?
SOCIAL HISTORY
Do you use any tobacco?
Yes
No
Do you vape?
Yes
No
If Yes, what?
How often/much?
Do you drink alcohol?
Yes
No
If Yes, what kind/how much/often?
Any drug use?
Yes
No
If Yes, what kind/how much/often?
History of drug overdose?
Yes
No
If Yes, when?
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FAMILY HISTORY
Is there obesity in the family?
Yes
No
If Yes, please list:
Are there any medical illnesses in your immediate family?
Yes
No
Medical Illnesses
Rows
Yes
No
Who?
Type:
Diabetes?
Hypertension?
Coronary Artery Disease?
Cancer?
Other?
WEIGHT LOSS ATTEMPT HISTORY
Please list ALL weight loss attempts, physician-supervised programs, as well as self-monitored diets. Please take the time to be as thorough as possible.
Age you first started dieting:
Type of diet (ex: Keto Diet, Jenny Craig, Weight Watchers, weight loss medication, etc.):
List any other physician-supervised and documented weight-loss attempt(s):
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Weight Management Patient History Questionnaire
FOOD INTAKE
What specific food plan/diet are you currently following, if any?
How many meals do you consume per day?
Do you skip meals?
No
Yes
Do you eat breakfast?
No
Yes
How late is your dinner?
Number of snacks per day:
When is your typical bedtime?
Do you snack after dinner?
No
Yes
Sometimes
Do you snack between meals?
No
Yes
If so, what and how often?
Do you have any eating related problems or concerns?
No
Yes
If yes, please explain:
Are you willing to cook, or do you prefer purchasing meals?
No
Yes
Do you have any diet restrictions?
Rows
No
Yes
Text
Vegetarian
Gluten free
Other
What is your daily protein intake from drinks and/or food?
How much WATER do you drink in a 24-hour period?
24oz (3 cups or less)
32oz (4+ cups)
64oz (8+ cups)
Other
What do you drink other than water?
How much?
LIST YOUR FOOD INTAKE FROM YESTERDAY
Rows
Time
Place
Food/Beverage
Amount
Breakfast
Lunch
Dinner
Snack
Snack
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PHYSICAL ACTIVITY
Do you exercise regularly?
No
Yes
Do you have any physical restrictions that keep you from exercising?
No
Yes
If yes, explain
Exercise Regime
Rows
Intensity
Daily
How often
Comments
Walking
Weight Training
Cardio
Swimming
Yoga
Other
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PERSONAL MEDICAL HISTORY
Do you have or have you had any of the following? Check all that apply.
Do you have any of the following? (Please check all that apply)
Depression
Panic attacks
Anxiety
Bipolar disease
Eating disorder
Obsessive Compulsive Disorder
Other
Treatment and Medication
Rows
No
Yes
Seeking treatment ?
Are you taking medication?
Do you have a history of suicide attempt or suicidal ideation?
No
Yes
If so, when?
Are you currently seeing a psychologist/psychiatrist/therapist?
No
Yes
Sleep Health
Rows
No
Yes
Hours of sleep
How many hours do you typically sleep per night?
If you have insomnia, do you have trouble falling asleep or staying asleep?
Has anyone told you that you snore loudly or stop breathing for a few seconds during sleep?
Do you have excessive daytime sleepiness?
Have you been diagnosed with Sleep Apnea?
If yes, are you currently on CPAP or other oral device?
Cardiovascular Health
Rows
No
Yes
When?
High Blood Pressure?
If yes, medication?
Heart Attack?
Heart Bypass Surgery?
Stents?
Pacemaker?
Endocrine Health
Rows
No
Yes
When?
Diabetes?
If yes, medication?
Thyroid problems?
Medications?
Gastrointestinal Health
Rows
No
Yes
How often?
Heartburn?
If yes, medication?
Do you get pain in your upper abdomen after eating or in the middle of the night, other than heartburn?
Have you ever been told you have gallstones?
Have you ever been told you have a fatty liver?
Respiratory Health
Rows
No
Yes
Do you have asthma?
Do you have COPD/Emphysema?
If yes, medications?
Have you ever been told you have a fatty liver?
How far can you walk before you get short of breath?
Musculoskeletal Health
Rows
No
Yes
If yes, please give details?
Do you have joint pain?
If yes, medications?
Have you seen an orthopedic MD for this?
Have you had surgery for this?
Are you waiting for a joint replacement until you lose weight?
Gynecologic and Obstetric
Age at onset of periods:
Frequency:
Length of Period:
Pregnancies:
Births:
Miscarriages:
Prolonged or abnormal bleeding?
No
Yes
If yes, describe:
Any other medical history/conditions besides listed above? (Include Medication/Food Allergies)
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Medications
(Including vitamins - please attach medication list if applicable)
Medication
Rows
Medication Name
Dosage
Frequency
Comments
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Submit
Should be Empty: