Weight Loss Program Questionare - Healthy Outcomes



Weight loss Profile

Dietary consultation involves a weight loss profile. Its purpose is not to establish a diagnosis, but rather to determine a patient’s health status in order to guide his or her weight-loss plan. A patient may be advised to seek medical advice based on his or her weight loss profile.

General

Name ___________________________________ Age: ___________ DOB_________

How did you hear about our program? ______________________________________

Job/Occupation:________________________ Who is your doctor? ___________________

Email Address_____________________________________

Do you have any of the following:

____ High blood pressure ____ Kidney disease ____ Liver disease

____ Heart disease ____ Lactose intolerance ____ Illicit Drug Use

____ High cholesterol ____ Celiac disease ____ Gout

____ Thyroid disease ____ Colon problems ____ Acid reflux

____ Low Energy ____ Constipation ____ Trouble sleeping

____ Anxiety/Stress ____ Diverticulosis ____ Joint problems/aches

____ Prostate problems ____ Cramps (PMS) ____ Bloating

____ Yeast Infections ____ Food Cravings ____ Eating Disorders (Bulimia/ Anorexia)

____ Kidney stones ____ Sleep Apnea ____ Juvenile Diabetes/ Pre-Diabetes/ Diabetes

____Ulcer ____TIA’s (ministrokes) ____Depression

____Glaucoma ____Pacemaker/ Defibrillator

Please list any other medical problems you have:

_______________________________ ____________________________

_______________________________ ____________________________

Are you pregnant? ____ Yes ____ No

Do you smoke? ____ No ____ Yes (How much, and how often?________________________)

Do you drink alcohol? ____ No ____ Yes (How much, and how often? _________________

_________________)

Do you take a multivitamin? ____Yes ____

Do you take Fish Oil? ___ Yes ___No

Do you take any medications (including prescriptions, over-the-counter, vitamins)?

__________________________________ _________________________________

__________________________________ _________________________________

Are you allergic to any medicines or foods? ________________________________________

_______________________ ________________________ ____________________________

Have you ever had your metabolism tested? ____No ____Yes (By who?________________)

Do you exercise? ____ Yes ____ No

-If yes, how many days/week_______ Minutes each day_________, and what is your exercise of choice____________________________________________?

What is your goal: ____ Weight loss ____ Muscle size ____ Fitness ____ Flexibility ___ Health

Please name your 2 favorite foods: __________________________________________

__________________________________________

What types of food do you usually crave? ________________________

________________________

Do you think that eating food gives you a lot of pleasure? ____ Yes ____ No

Do you look for food when you are sad or stressed? ____ Yes ____ No ____ Sometimes

Do you ever find yourself eating after you feel full/satisfied? ____Always ____Often

____ Rarely ____ Never

Have you ever tried to lose weight before? ____ Yes ____ No

If yes, please tell us how: ______________________________________________________

If yes, please specify which diet and why you think it didn’t work for you (ex) too complicated, too much cooking involved, etc.): ____________________________________

____________________________________________________________________________

Have you had bariatric surgery (surgery for weight loss)? ____ Yes ____ No

What time do you usually eat: Breakfast: _________ Lunch:__________

Dinner:_________ Snacks:__________

Please give an example of a typical breakfast, lunch, dinner and snack.

(Please be specific, ex. 2 slices of toast with butter, 8 oz. O.J., 8 oz. coffee with 2 tablespoons of sugar and cream)

A typical breakfast:

________________________________________________________________________

A typical lunch:

________________________________________________________________________

A typical dinner:

_________________________________________________________________________

A typical Dessert:

(Only if you have dessert after most meals)

_______________________________________________________________________

A typical snack:

________________________________________________________________________

Which one is your largest meal of the day? ___________________________________

Which meal(s) do you tend to skip? _________________________________________

Do you dine out, stop for fast food, or pizza? ___No ___Yes How often?__________

Do you want us to send progress reports to your doctor? ____ Yes ____ No

What is your current weight?___________lbs.

What was your highest weight?__________lbs.

What is your goal weight? ______________lbs.

When did you begin to gain weight?_______________________________________________

How long have you been overweight?______________________________________________

Please tell us the main reason(s) why you want to lose weight: _________________________

Any additional information you would like for us to know?

_____________________________________________________________________________________

No potential dieter is to be placed on a high protein protocol with a history of or current diagnosis of the any following conditions without written consent from his/her primary care provider or specialist monitoring this patient.

• History of cardio-vascular events: (i.e. heart attack, stroke, aneurysm, by-pass, stent surgery, history of having cardiac arrhythmia including having a pace-maker)

• History of or current active cancer, including skin cancers

• Pregnant female (note from OB/GYN ONLY)

• Breast feeding female

• Severe Liver Disease

• Severe Kidney Disease

• Diagnosis or history of congestive heart failure (CHF)

• Patients currently on Lithium therapy

• Patients with a diagnosis of Parkinson’s Disease

I agree to consult with my primary care physician to guarantee the safety of the recommendations made to me for weight management and exercise.

________________________________ __________________________________

Patient Witness

Reviewed by Physician

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