Weight Management Questionnaire

Weight Management Questionnaire Patient Name ____hhhh________________________ Date____________________________________ Please answer each of the questions below. The information you share will help the Registered Dietitian have a better understanding of your needs. 1. Are you concerned about your weight? ¨ No (Skip to question 4) ¨ Yes, I want to stop gaining weight. (Skip to question 4) ¨ Yes, I want to lose weight. 2. What do you think weighing less would do for you? In the next few months: In the next year or two: 3. What is your goal weight? ________________________________lbs. 4. What was your lowest adult weight? __________ Age at this weight? __________ What was your highest adult weight? __________ Age at this weight? __________ 5. Do you take any vitamin, mineral, herbal, or other dietary supplements (for example protein powders?) ¨ Yes List __________________________________________________________ ¨ No 6. Do you smoke cigarettes? ¨ Yes – How many in a typical day? ______________ ¨ No 7. Are you currently on a diet or taking prescribed or across-the-counter medication to lose weight or to maintain your current weight? ¨ No ¨ Yes, I am on a diet. Describe the diet: ¨ Yes, I am taking medications. List medications: 8. Have you tried to lose weight in the past? ¨ No (Skip to Question 10.) ¨ Yes – check all that apply. o Diet(s) Describe. o Medications List. o Other – Describe. 9. If yes to number 8, did you lose weight? ¨ No ¨ Yes ___________________ lbs. over this period of time ____________________ How much of this weight, if any, did you gain back? ____________________ lbs. What worked best for you and why? 10. In the past year, have you tried to lose weight or control your weight by vomiting, taking diet pills or laxatives, or not eating? ¨ Yes ¨ No 11. Do you ever feel that your eating is out of control? ¨ No ¨ Yes – explain: 12. Do you participate in regular physical activity? ¨ No (Skip to question 13.) ¨ Yes – Describe LIST YOUR ACTIVITIES HOW MANY TIMES A WEEK DO YOU DO THIS ACTIVITY? HOW MUCH TIME DO YOU SPEND IN THIS ACTIVITY IN A TYPICAL WEEK? 1. 2. 3. 4. 5. 6. 13. Put an X on the line below to show on a scale from 0 to 10, how important it is for you to make lifestyle changes? (Lifestyle changes are changes to improve your health, such as adjusting your diet, increasing your physical activity, and changing health-related behaviors.) …………………………………………………………………………………………… 0 5 10 Not very important Somewhat important Very important 14. Put an X on the line to show how ready you are right now, on a scale of 0 to 10, to make lifestyle changes. ….…………………………………………………………………………………………… 0 5 10 Not Very Ready Somewhat ready Very ready 15. Put an X on the line to show how confident you are, on a scale of 0 to 10, that you can make lifestyle changes? ….…………………………………………………………………………………………… 0 5 10 Not Very confident Somewhat confident Very confident