Arthritis Osteoporosis Other: ________
1. Present weight: Height (no shoes): Desired weight:
2. In what time frame would you like to be at your desired weight? ________________
3. Birth Weight: Weight at 20 years of age: Weight one year ago: __
4. What is the main reason for your decision to lose weight? ______________________
5. When did you begin gaining excess weight? (Give reasons, if known); ___________
6. What has been your maximum lifetime weight (non-pregnant) and when?
7. Previous diets you have followed: Give dates and results of your weight loss:
8. Is your spouse, fiancée or partner overweight? Y N
By how much is he or she overweight?
9. How often do you eat out?
10. What restaurants do you frequent?
11. How often do you eat “fast foods”?
12. Who plans meals? Cooks? Shops?
13. Do you use a shopping list? Y N
14. What time of the day and what day do you shop for groceries?
15. Food Allergies (list):
16. Food dislikes (list):
17. Foods you crave:
18. Any specific time of the day or month do you crave food?
19. Do you drink coffee or tea? Y N How much daily?
20. Do you drink soft drinks? Y N How many daily? Diet or regular?
21. Do you drink alcohol? Y N How much?
22. Do you use a sugar substitute? Y N
23. Do you awaken hungry during the night? Y N
What do you eat?
Have you ever found evidence of night time eating without your knowledge?____________
24. What are your worst food habits?
Do you “binge eat? Y___ N ___ How often? ____________
25. Have you ever induced vomiting or taken laxatives or diuretics for weight loss?
Have you ever been diagnosed with bulimia? Y____ N___
Have you ever been diagnosed with Anorexia Nervosa? Y___ N___
26. Snack Habits: What?
27. When you are under a stressful situation at work or family related, do you tend to reach more?
28. Do you think are currently undergoing a stressful situation or an emotional upset?
29. Smoking habits: (answer only one)
____ You have never smoked cigarettes, cigars or a pipe
____ You quit smoking ___ years ago and have not smoked since
____ You have quit smoking cigarettes at least one year ago and now smoke cigars or a pipe without
____ You smoke 20 cigarettes per day (1 pack)
____ You smoke 30 cigarettes per day (1 and ½ packs)
____ You smoke 40 cigarettes per day (2 packs)
30. Typical Breakfast Typical Lunch Typical Dinner
Time eaten: Time eaten: Time eaten:
Where: Where: Where:
With whom: With whom: With whom:
31. Describe your usual energy level:
32. Activity Level: (answer only one)
____ Inactive—not regular physical activity with a sit-down job.
____ Light activity—no organized physical activity during leisure time.
____ Moderate activity—occasionally involved in activities such as weekend golf, tennis, jogging,
swimming or cycling.
____ Heavy activity—consistent lifting, stair climbing heavy construction, etc. or regular
____ Vigorous activity—participation in extensive physical exercises for at least 60 minutes per
session 4 times per week.
33. Behavior style: (answer only one)
____ You are always calm and easy going.
____ You are usually calm and easy going.
____ You are sometimes calm with frequent impatience.
____ You are seldom calm and persistently driving for advancement.
____ You are hard-driving and can never relax.
Current Symptoms (please circle if present)
Appetite Increase Appetite Decrease Chills Fatigue Fever Sweats
Eyes- Last check up (Date or how long ago)__________
Blurred vision Double vision Cataracts Eye pain Redness Glaucoma Recent change in vision
Decreased hearing Pain Ringing Use of hearing device
Allergies Congestion Obstruction
Enlarged tonsils Snoring Sore throat Trouble swallowing
Chest pain or pressure Fainting or black out spells Heart murmur
Palpitations(racing heart or skipped beats) Shortness of breath Trouble lying flat
Swelling in legs or feet
Congestion Cough Rattling or wheezing
Stomach and gastrointestinal Last colonoscopy (year) ______
Bloody stools Cramps Constipation Diarrhea Heartburn or reflux Nausea Pain Vomiting
Muscles, joints, and bones
Arthritis Back pain Joint pain or stiffness (where)______________________________________
Morning stiffness Muscle pain Muscle weakness
Acne Dry or scaly Itching Lump, nodule, or mole (where)______________ Nail changes
Breast Last mammogram___________
Discharge Lump Pain Rash or redness
Forgetfulness Numbness Weakness
Anxiety Crying spells Depression Insomnia Panic attacks Rage or temper problems
Excessive hunger Excessive thirst Decreased libido Hoarseness Recent hair growth
Hormones (Female) Last female exam ________
Change in periods
Blood and circulation
Clotting problems Easy bruising
Allergy and immune
Frequent infection Seasonal allergies
Please describe your general health goals and improvements you with to make:
What kind of dietary approach do you feel is best for you? (Circle one, feel free to leave blank, we’ll go over
this): ALL FOOD, PARTIAL MEAL REPLACEMENT (USE A MEAL REPLACEMENT
FOR ONE OR MEALS DAILY, OR TOTAL MEAL REPLACEMENT (Very low calorie “protein
sparing fast for quicker weight loss).
Do you feel you will need medication for appetite suppression?
Do you want vitamin B