NEW CLIENT HEALTH HISTORY QUESTIONNAIRE
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Who were you referred by?
First Name
Last Name
What is your level of motivation to start the program?
Highly Motivated
Moderately Motivated
Somewhat Motivated
Gathering Information
Please describe your reasons for wanting to lose weight.
WEIGHT HISTORY AND HEALTH BEHAVIORS
Weight History
1. Was there an age at which you felt that weight became a concern for you?
Yes
No
If YES, when?
Childhood
Teenage Years
Adulthood
Pregnancy
Menopause
2. Have there been any circumstances or life events that have triggered weight gain for you?
Pregnancy
Job Change
New Medication
Stress
Boredom
Other
If OTHER, please briefly describe.
3. What was your weight one year ago?
4. What has been your highest weight?
5. What was your lowest adult weight?
6. Have you attempted to lose weight in the past? If so, please select the program/method you used. Select all that apply.
Weight Watchers
Nutrisystem
Jenny Craig
LA Weight Loss
Atkins
South Beach
Zone Diet
Medifast
Dash Diet
Paleo Diet
HCG Diet
Mediterranean Diet
Ornish Diet
Weight Loss Clinic
Other
If you selected OTHER, please briefly explain.
If you selected WEIGHT LOSS CLINIC, which one did you attend?
7. Have you ever used any prescription medications for weight loss? Select all that apply.
Phentermine (Adipex)
Xenecal / Alli (Orlistat)
Phen / Fen
Phendimetrazine (Bontril)
Topamax
Saxenda (Liraglutide)
Diethylpropion
Bupropion (Willbutrin)
Wegovy (Semaglutide)
Qsymia (Phentermine / Topiramate)
Contrave (Naltrexone / Bupropion)
Zepbound
Other
If you selected OTHER, please briefly explain.
If you took any weight loss medication how much weight did you lose with the medication and did you experience any side effects?
8. Is your weight affecting your health and your life?
9. What do you consider some of your barriers when it comes to managing your weight? Select all that apply.
Hunger
Work
Cravings
Fatigue
Finances
Time
Knowledge
Other
If you selected OTHER, please briefly explain.
10. What are your goals / anticipated outcomes from this program?
Nutrition
1. How do you feel about your current eating habits?
Could be better
Pretty good overall but there is room for improvement
I have great habits
2. Are you currently following a particular eating plan?
Yes
No
If you selected YES, which one?
Low fat
Low carb
Keto
Mediterranean
Vegan
Other
If you selected OTHER, please briefly explain.
3. Have you tried any particular eating plans or diets in the past?
Yes
No
If you selected YES, which ones have you tried, and which ones worked or did not work for you?
4. On average how many meals do you consume per day?
5. On average how many snacks do you consume per day?
6. Do you have any food allergies or intolerances? Select all that apply.
Gluten Allergy
Gluten Intolerance
Dairy Allergy
Dairy Intolerance
Tree Nut Allergy
Tree Nut Intolerance
Egg Allergy
Egg Intolerance
Soy Allergy
Soy Intolerance
Fish/Shellfish Allergy
Fish/Shellfish Intolerance
Other
If you selected OTHER, please briefly explain.
7. Who typically does most of the grocery shopping in your household?
8. Who typically does most of the cooking in your household?
9. Do you have any food preferences including ethical or cultural considerations? Please briefly explain.
10. How many times per week do you eat food or drink beverages from a restaurant?
Never
1-3 times per week
4-6 times per week
More than 7 times per week
11. What are your triggers for eating. Select all that apply.
Hunger
Stress
Boredom
Cravings
Time of Day
Other
If you selected OTHER, please briefly explain.
12. What are your barriers to eating healthy. Select all that apply.
Cooking Skills
Time
Financial Reasons
Access to Healthy Foods
Schedule
Home/work Circumstances
Other
If you selected OTHER, please briefly explain.
13. Do you have any current or past history of an eating disorder?
Yes
No
If YES, please briefly explain.
Physical Activity
1. How many days per week do you engage in moderate to vigorous physical activity, such as a brisk walk or an exercise class?
1-2 times per week
3-4 times per week
5 or more times per week
Never
2. How many minutes does each exercise session typically last?
10 mins or less
10-20 mins
20-30 mins
more than 30 mins
3. What type of activities do you participate in regularly? Select all that apply.
Walking
Biking
Strength Training
Yoga
Other
If you selected OTHER, please briefly explain.
4. Please list any barriers to physical activity. i.e. Time, Joint Pain, Motivation, etc.
5. What type of equipment/spaces do you have available to you to engage in physical activity?
Gym Membership
Stationary Bike
Free Weights
Walking Path
Other
If you selected OTHER, please briefly explain.
6. What types of activities do you enjoy or have enjoyed in the past?
Alcohol
1. Do you drink alcohol?
Yes
No
If YES, what kind. Select all that apply.
Beer
Wine
Liquor
Cocktails
Other
If you selected OTHER, please explain.
2. How many drinks per week do you typically consume?
1-3
4-7
more than 8
None
3. Are you concerned about the amount of alcohol you consume?
Yes
No
Caloric Beverages
1. Do you drink caloric beverages such as soda, juice, sweetened tea, or coffee with creamer or sweeteners?
Yes
No
If YES, what kind?
2. How many ounces per day do you consume on average?
Sleep
1. How many hours of sleep do you average per night?
Less than 5
6-8 hours
9 or more hours
2. Do you work a night shift or shift work?
Yes
No
3. What is your usual bedtime?
Hour Minutes
AM
PM
AM/PM Option
4. What is your usual waking time?
Hour Minutes
AM
PM
AM/PM Option
5. Do you have trouble falling or staying asleep?
Yes
No
6. Have you ever been evaluated for sleep apnea or other sleep related disorders?
Yes
No
If you selected YES, were you diagnosed with sleep apnea?
Yes
No
If you selected YES, do you use a CPAP, BiPap or other device? Please briefly explain.
7. Do you snore loudly?
Yes
No
8. Are you tired throughout the day?
Yes
No
9. Has anyone observed that you stop breathing during sleep?
Yes
No
10. Do you often wake up with headaches in the morning?
Yes
No
11. Do you take naps during the day?
Yes
No
Occupation and Home Life
1. How many people live with you in your home?
2. If there are children in your home, please indicate their ages.
3. What is your occupation?
4. Do you have a good social support system for healthy lifestyle changes?
Yes
No
If you selected YES, please list your support circle.
Mental Health
1. Rate your stress level on a scale from 1 to 10:
2. Do you feel like you have healthy coping mechanisms for stress?
Yes
No
3. Please briefly explain how you cope with stress.
4. Do you consider yourself an "emotional eater?"
Yes
No
5. Have you ever been diagnosed with a mental health condition?
Yes
No
If you selected YES, which mental health condition were you diagnosed with?
6. Are you currently under the care of a mental health counselor or therapist?
Yes
No
7. Are you currently under the care of a psychiatrist?
Yes
No
Women Only
1. To the best of your recall, at what age did you begin your menstruation cycle?
2. What was the date of you last menstruation cycle?
-
Month
-
Day
Year
Date Picker Icon
3. Do you experience any of the following? Select all that apply.
Heavy Menstruation Cycles
Irregular Menstruation Cycles
Regular Spotting
Discharge
Pain
None of the Above
4. Number of Pregnancies
5. Number of live births
6. Are you currently pregnant?
Yes
No
7. Are you currently breastfeeding?
Yes
No
8. Are you planning a pregnancy within the next year?
Yes
No
9. Do you experience any problems with control of urination?
Yes
No
10. Have you ever been diagnosed with PCOS?
Yes
No
11. Have you been affected by infertility?
Yes
No
12. Date of last pap?
-
Month
-
Day
Year
Date Picker Icon
Men Only
1. Do you usually get up to urinate during the night?
Yes
No
If you selected YES, how many times per night do you get up?
2. Do you experience erectile dysfunction?
Yes
No
3- Day Nutrition History
Day 1
Time
Food & Beverages Consumed
Place Consumed
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Day 2
Time
Food & Beverages Consumed
Place Consumed
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Day 3
Time
Food & Beverages Consumed
Place Consumed
Breakfast
Snack
Lunch
Snack
Dinner
Snack
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