Have you had any of these health problems in the past or present? (circle all that apply)

Cancer	Eating Disorder	Gallbladder Disorder	Moodiness
Rashes	Bronchitis	Drug Abuse	Frequent Urination
Insomnia	Heart Paplitations	Constipation / Diarrhea	Fainting Spells
Glaucoma	Nervouness / Anxiety	Dizzy Spells	Fatigue
Headaches	Obesity

Do you have any surgeries planned in the near future?  If so, please describe below:
________________________________________________________________________________

Health Habits:
Exercise:         
____ Sedentary
____ Mild Exercise (i.e. walking, golf)                       
____ Occasional high intensity exercise (i.e. sports, running/jogging 1-3 times/week)
____ Regular high intensity exercise (i.e. sports, running/jogging 4+ times/week)

Diet:
Are you currently on a diet?                  Yes          No
If so, is it medically supervised?            Yes          No
How many times do you eat a day?        ____________meals       ___________snacks
How much water do you drink a day?     ___________glasses/cups/liters          

Caffeine:
Do you drink caffeinated beverages?     Yes         No
What types of caffeine do you drink?     Soda      Tea       Coffee       Other__________
How many cans/cups per day?               __________cups/cans

Drugs:
Are you currently using illicit drugs?        Yes       No
Have you used illicit drugs in the past?     Yes       No
If so, please list type and years used:
___________________________________________________________________________
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Women only:        
Are you pregnant?                                       Yes         No
Are you trying to get pregnant?                    Yes         No
Are you breastfeeding?                                Yes         No
If you are not trying to get pregnant, what method of birth control are you using?
___________________________________________________________________________
How old were you at the onset of menstruation?_______years. Date of last menstruation ________
How often do you get your period (days)?_____. Are your periods…  Heavy      Irregular     Painful

Weight History:
1.)  What made you decide that you wanted to lose weight?

2.)  When did you start to become overweight?  

3.)  What do you attribute your weight gain to?

4.)  What other ways have you attempted to lose weight?  What are the reasons that you think these attempts didn’t work for you?

5.)  Is your spouse or significant other overweight?

6.)  Do you feel that the people that you live and work with would support your efforts to lose weight?

7.)  Do you have any food allergies?

8.)  What foods do you avoid?

9.)  What foods do you crave?

10.)  What are your worst food habits?

11.)  What do you feel are your biggest challenges when it comes to weight loss?

12.)  Do you eat breakfast?  If so, what do you typically eat?

13.)  What time do you eat lunch? What do you typically eat?

14.)  What time do you eat dinner?  What do you typically eat?

15.)  Do you like to exercise?  Do you play sports or are there any activities such as gardening or walking the dog that you enjoy?

16.)  Please add any additional comments that you think would be helpful in creating a weight loss plan that works best for you.

Patient Signature ______________________________________________