Clinical Weight Loss Program Questionnaire

1. Patient Information

Full Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Phone Number

Email Address*

Address

Street Address City Apartment Number ZIP / Postal Code Country

Emergency Contact Name:

First Last

Emergency Contact Phone:

Primary Care Provider (PCP):

Referring Provider

2. Weight History and Goals

Current Weight (Pounds)*

Goal Weight (Pounds)*

Lowest Adult Weight (Pounds)

Highest Adult Weight (Pounds)

Height (Feet)*

When did weight gain begin?

What factors do you believe contributed to weight gain?

How many pounds would you like to lose?

What are your top three goals for this program?

What have you tried in the past to lose weight? What worked and what did not?

3. Medical History

Please check any condition you currently have or have had in the past:

Diabetes or prediabetes

High blood pressure

High cholesterol

Heart disease

Stroke

Thyroid disorder

Sleep apnea

Asthma or lung disease

Liver disease

Kidney disease

Gallbladder disease

Gastroesophageal reflux

Seizures

Migraine

Depression

Anxiety

Eating disorder

Chronic pain

Arthritis

Polycystic ovary syndrome (PCOS)

Infertility

Cancer

Other

Other significant medical conditions

List any medical diagnoses and the year of diagnosis

Past surgeries and dates

Hospitalizations / emergency room visits in the past 5 years

Are you currently under the care of any specialists?

Yes

Please list:

4. Medications and Allergies

Current Medications

Do you currently take any prescription medications?

Yes

Please list all current prescription medications, doses, and how often you take them

List all prescription medications, over-the-counter medications, vitamins, herbal products, and dietary supplements.

Medication allergies and reactions

Food allergies or intolerances

Have you ever taken weight-loss medication?

Yes

Please list which one(s) and what was your experience?

5. Lifestyle and Nutrition

Describe a typical day of eating (meals, snacks, beverages)

How many servings of fruits and vegetables do you usually eat each day?

How often do you eat restaurant or takeout meals?

How many sugary or alcoholic beverages do you consume each week?

How many days per week do you exercise?

What types of physical activity do you do?

Average hours of sleep per night

Do you snore or feel excessively sleepy during the day?

Do you use tobacco or nicotine products?

Yes

If yes, please describe

How would you rate your stress level? What are your main stressors?

6. Program Screening

Are you currently pregnant, planning pregnancy, or breastfeeding?

Yes

Do you have a history of pancreatitis, gallstones, or thyroid cancer?

Yes

Do you have a history of binge eating, purging, or severe food restriction?

Yes

Do you have any limitations that affect your ability to exercise safely?

Yes

What motivates you to lose weight now?

How confident do you feel about making nutrition and activity changes? (1-10)

What barriers might make it difficult for you to follow the program?

7. Patient Acknowledgment

Patient Full Legal Name*

By typing my full legal name below, I certify that I have read and understand this document and agree that my typed name constitutes my legally binding electronic signature.

Name

Consent*

I certify that the information I have provided is true, complete, and accurate to the best of my knowledge. I understand that this questionnaire is intended to assist my healthcare provider with clinical screening, evaluation, and treatment planning and is not a substitute for professional medical advice, diagnosis, or treatment.

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Date*

Month

Day

Year