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Weight Management Questionnaire
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Weight Management Questionnaire
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Name
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DOB
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MM slash DD slash YYYY
Weight History
1. What do you consider a good weight for yourself?
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Current Weight
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2. What is the most you have weighed?
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Most weighed at what age?
3. What is the least you have weighed as an adult?
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Least weighed at what age?
4. Have you gained or lost weight recently
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How much?
How much?
5. Is your spouse overweight?
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Is your Children overweight?
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Is your Parents overweight?
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Is your Siblings overweight?
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6. How long have you been overweight?
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7. How many glasses/oz. of water do you drink a day?
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8. How many hours of sleep do you get a night?
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9. How many meals do you prepare at home a week?
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Related Factors
What do you see as your reason(s) for being overweight or overeating? Click those that apply.
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type of food
portions
alcohol
snacks
travel or eating out
habits
socializing
lack of food knowledge
watching TV or movies
depression
anger
boredom
nervousness
stress
quit smoking
enjoy food
comfort
job
fatty foods
sugar/sweets
fast foods
soft drinks
desserts
escape
meat
convenience
lack of time
unplanned meals
no support
conflicts
inconsistent mealtimes
other
List diets and/or weight-loss plans you have followed in the past:
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Weight Loss Plans - Which worked?
List Weight loss medications or supplements that you have tried in the past:
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Weight Loss Medications - Which worked?
What is your biggest challenge regarding weight loss?
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Behavioral
Why do you want to lose weight? Click those that apply.
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Health
Feel better
Improve physical fitness
Physician/Nutritionist advice
Appearance
Clothes fit better
Pressure from family/friends
other:
Do you feel sad most days?
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Yes
No
Do you have a decreased pleasure in normal activities?
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Yes
No
Do you have difficulty sleeping or significantly increased need to sleep?
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Yes
No
Do you feel guilty or worthless?
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Yes
No
Do you have a low energy level?
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Yes
No
Do you think of injuring yourself or others?
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Yes
No
Do you have difficulty making decisions or concentrating?
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Yes
No
Eating Habits
How many meals a day do you eat?
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What meals do you primarily eat?
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Describe which foods you typically eat in a day?
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What are your favorite foods?
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What foods do you dislike?
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Exercise
Do you exercise?
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What forms of exercise have you tried?
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Medical
Have you ever been diagnosed with hypertension?
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Yes
No
Have you ever been diagnosed with thyroid issues?
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Yes
No
Have you ever been diagnosed with any cardiac issues?
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Yes
No
Have you ever been diagnosed with depression?
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Yes
No
Name
This field is for validation purposes and should be left unchanged.
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