Medical Weight Loss Form

Are you in good health at the present time to the best of your knowledge?*

Are you under a doctor’s medical supervision at this time?*

Please list your current medications*

Please list your current supplements*

Please write your Present Weight, Height, Desired Weight*

When would you like to be at your desired weight?*

Why do you want to lose weight? (Health Benefit? Appearance?) Please explain thoroughly:*

When did you begin gaining weight?*

What do you believe caused your weight gain?*

What has been your maximum weight (non-pregnant) and when?*

Have you tried other weight loss programs? If yes which ones.*

How often do you eat out?*

What restaurants do you frequent?*

How often do you eat “fast foods”?*

Food allergies?*

Food dislikes?*

Food cravings?*

Do you eat because of emotions (explain)?*

Do you drink coffee or tea? If Yes, how much daily?*

Do you drink pop / soft drinks? If Yes, how much daily?*

Do you use sugar substitutes?*

What are your worst food habits?*

When there is increased stress in your life, do you tend to eat more?*

Describe your typical breakfast*

Describe your typical lunch*

Describe your typical dinner*

Describe your snack habits, how often, what foods?*

Describe your energy level*

Activity Level: (check one)*

On a scale of 1 to 10 with 10 being MOST committed, how committed are you to taking action and making a change in your life today?*