Weight Loss Program Consultation Name: * First Name Last Name Date of Birth: * MM DD YYYY What is your current weight? * What is your current height? * What led to your weight gain? * What was your weight as a young adult? * What weight did you feel your best at? * What is your goal weight? * Prior weight loss diets that did not work: * Prior weight loss diets that did work: * Prior weight loss medications: * Current weight loss medications: * Current diet: * Current eating patterns: * How much water do you drink a day? * How many diet sodas do you drink a day? * Strongest Cravings: * Salt Sugar Other Portion Sizes: * Not an issue Too large Any food allergies or intolerances? If yes, what? * History of eating disorder? If yes, what type and when? * Current eating disorder? If yes, what type? * Current exercise regimen: * If female, are you pregnant? Yes No Alcohol intake: * How many hours a night do you sleep? * How many times do you wake at night? * Sleep Apnea Screening Do you snore loudly? * Yes No Are you tired, fatigued or sleepy during the daytime? * Yes No Observed apnea, choking or gasping while asleep? * Yes No High blood pressure? * Yes No Age older than 50? * Yes No Neck size large (shirt collar 16"/40cm measured at Adam's apple)? * Yes No Medical problems that you feel are weight-related: * What are your goals besides weight loss? * Waist circumference at your umbilicus in inches: * Hip circumference at the widest part: * Symptom Baseline Screening In the past 14 days, how often have you experienced the following symptoms: Fatigue: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Insomnia: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Aching: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Stiffness: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Headaches: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Shortness of Breath When Walking Up a Hill: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Heartburn, Indigestion: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Constipation: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Anxiety: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Depression: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Poor Memory: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Poor Concentration: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe Low Sex Drive: * 0 - Never or almost never have the symptoms 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe
