Weight Loss FormLoading... First Name Last Name Address City State Zip Phone Email Birthdate Approximate current weight Approximate goal weight How would reaching your ideal weight change your life? What are your biggest challenges/pitfalls/barriers to losing weight? How committed are you to making this weight change in your life with this program right now? (9 = Nothing can get in my way! 0 = If it happens, it happens) 0 1 2 3 4 5 6 7 8 9 Do you have any of the following? (Please check all that apply) High Cholesterol Psoriasis Peptic Ulcer Disease Gout Thyroid Disease Poor Liver Function Gallstones Arthritis Hair Loss Irritable Bowel Syndrome (IBS) Have you ever had cancer Diabetes Varicose Veins Gastro Esophageal Reflux (GERD) Hypoglycemia Sleep Apnea History of Heart Attack Irregular Heartbeat / Atrial Fibrillation None of the above Please rate your overall physical health. (range: 9 = Fantastic! 0 = Not well) 0 1 9 Do you have any specific health concerns? (Write NO if appropriate) To what extent do you enjoy your livelihood/occupation? (9 = I love it; 0 = not at all) 0 1 2 3 4 5 6 7 8 9 What are your top 3 favorite foods? How often do you find yourself sad or depressed without a definitive reason? (9 = nearly always; 0 = never) 0 1 2 3 4 5 6 7 8 9 Have you ever dieted before? (If NO, skip to question 28) Yes No What diets have you tried and how did they work for you? List each and describe the benefits and obstacles related to each diet. (Write NONE if you have never dieted) What was eating like in your family growing up? (e.g. did you have certain rituals like eating everything on your plate, receiving food as rewards, everyone paying attention to everyone else's food, eating as a fun family time, etc.) How often do you sit down to eat your meals? Never Rarely Occasionally Most of the time Every time Are you concerned about others being judgmental of your eating habits or your weight? If so, please describe your concerns. Do you have any eating habits that you feel particularly ashamed of? Do you frequently binge eat (extreme overeating)? Yes No Not Sure Do you sometimes eat when you're not really hungry? Yes No Not Sure Do you get short of breath walking up 2 flights of stairs? Yes No Not Sure What is your favorite exercise/activity? Do you enjoy exercising? (9 = I love it! 0 = not at all) 0 1 2 3 4 5 6 7 8 9 I'll look better. Not important Somewhat important Important Very Important Every time I'll be more attractive to others. Not important Somewhat important Important Very Important Every time I'll be able to wear more stylish clothes. Not important Somewhat important Important Very Important Every time I'll be happier when I look in the mirror. Not important Somewhat important Important Very Important Every time I won't feel so self-conscious. Not important Somewhat important Important Very Important Every time I'll be in better health. Not important Somewhat important Important Very Important Every time I'll be able to exercise without discomfort or embarrassment. Not important Somewhat important Important Very Important Every time I'll feel better. Not important Somewhat important Important Very Important Every time I'll be more physically fit. Not important Somewhat important Important Very Important Every time I'll feel as if I've accomplished something important. Not important Somewhat important Important Very Important Every time I'll increase my self esteem. Not important Somewhat important Important Very Important Every time I'll be less self critical. Not important Somewhat important Important Very Important Every time I'll do more things I would like to do (e.g. going to the beach). Not important Somewhat important Important Very Important Every time I won't have anyone bugging me about my weight. Not important Somewhat important Important Very Important Every time Dietary / Nutritional History What time of the day are you usually the most hungry? Morning Afternoon Evening Late Night What meal of the day is the largest? Breakfast Lunch Dinner Select the statement that best describes you (check one) TYPE I I can eat anything I want and not gain weight TYPE II I can lose or gain weight by adjusting my activity level and eating habits. TYPE III I find it very hard to lose weight. I gain weight very easily and have to watch everything I eat Are you a vegetarian or vegan? Approximately how may full meals do you eat a day? How often do you snack between meals each day? none 1-2 times >3 times Do you drink coffee regularly?If yes, how many cups a day? Do you drink soda regularly? If yes, how many cans/cups a day? How would you describe your typical eating habits: (check one) I eat a very healthy and balanced diet, consisting mostly of fresh fruit and vegetables, lean meats and plenty of water. I rarely eat “junk food” or fast food. I eat a moderately healthy diet, but on occasion eat unhealthy foods . I eat fast food more than 3 times a week. I drink sodas sometimes. I eat a mostly poor and unhealthy diet. I eat junk food almost everyday and fast food more than 4 times a week. I drink sodas often instead of water. Lifestyle & Activity What type of work do you do? _ Do you have children? Do you smoke?If yes, how often? Do you drink alcohol?If yes, how often? How often do you exercise (check one)? Rarely 1-2 days per week 3-5 days per week 6-7 days per week How long is your exercise activity per session? Rarely None <30 min 30-60 min 1 hr >1hr What Type of Exercise do you do regularly? (select all that apply) Yoga Jogging/Running Weight Training Bicycling Other How would you describe your general stress level? High Stress Moderate Low Stress How many hours of sleep do you get per night? <4 hours 4-5 hours 6-8 hours >8 hours How do you feel mostly throughout the day? Tired & Fatigued Energetic & Alert Confirmation * I agree that the data entered in the form may be processed and used solely for submitting information and advertising on products, services and other activities to my hand. Reset * Required
