North County Endocrinology
NAME: (full name)
YOUR SUPPORT FOR HEALTHIER YOU
Your Weight Management and Diabetes Prevention Support Team
PERSONAL INFORMATION
Sex:
DOB
-
Month
-
Day
Year
Date
Current Weight:
Height (lbs):
Max Weight (lbs):
Desired Weight:
WEIGHT RELATED CONDITIONS
WEIGHT RELATED CONDITIONS
Hypertension
Heart Conditions
PCOS
Diabetes
Stroke
Breathing disorder
Prediabetes
Sleep apnea
High Cholesterol/Lipids
History of pancreatitis
Personal or family history of Medullary thyroid cancer
History of gallstones or gallbladder surgery
History of eating disorder (anorexia, bulimia)
Other:
HOW LONG HAVE YOU BEEN TRYING TO LOSE WEIGHT
HOW LONG HAVE YOU BEEN TRYING TO LOSE WEIGHT
Less than 2 years
2-4 Years
More than 5 Years
WHAT DID YOU TRY
WHAT DID YOU TRY
Calories counting
Apps
Weight Watchers
Medications
Meal replacement
Other:
IF YOU WERE SUCCESFUL, HOW MUCH WEIGHT DID YOU LOSE:
EATING ROUTINES
HOW MANY MEALS A DAY:
WHAT IS YOUR BREAKFAST:
NONE
CEREAL
EGGS
TOAST
BAGEL
OTHER
LUNCH (what do you eat mostly)
DINNER (what do you eat mostly)
EXTRA MEAL
SNACKS:
YES
NO.
DURING THE DAY
BEDTIME
WHAT DO YOU SNAK ON:
WHAT DO YOU CARVE:
FAST FOOD OR RESTAURANTS (how many times per week):
HOW MANY SERVING OF FRUITS A DAY
EAT WHILE WATCHING TV:
YES
NO.
EAT TO IMPROVE MOOD:
YES
NO.
BINGE EATING ISSUES:
YES
NO.
SATIETY ISSUES (problems feeling full):
YES
NO.
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PHYSICAL ACTIVITES
WALKING/HIKING
SWIMMING
YOGA
AEROPIC
BIKE
PILATES
WEIGHTLIFTING
DANCING
GOLF
Other
HOW MANY TIMES A WEEK
WHAT ARE THE BARRIERS THAT PREVENT YOU FROM LOSING WEIGHT
BUSY SCHEDULE
LACK OF SUPPORT
MY FOOD CHOICES
HARD TO GET HEALTHY FOOD
LACK OF MOTIVATION
MY METABOLISM
I HAVE NOT TRIED HARD ENOUGH
FOOD NOISE
Other
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