Patient Weight Assessment

General Nutrition
Name: How many daily servings of
None
1 2
3 4
DOB: Sex: vegetables do you eat?
5 6
More
Height: Weight:
How many daily servings of
None
1 2
3 4
Race:
fruit do you eat?
5 6
More

Medical History How many daily servings of
None
1 2
3 4

Date of last check-up: grains do you eat?
5 6
More
Allergies: How many daily servings of
None
1 2
3 4
Previous meat do you eat?
5 6
More
Medications: How many daily servings of
None
1 2
3 4
Injuries: sugar/carbs do you eat?
5 6
More
Surgeries: How often do you
Never
Rarely
1 2 times
Blood Pressure: snack? per day
Between every meal
Cholesterol:
How often do you
Never
Occasionally
1 cup
drink coffee/tea? per day
2 3 cups
4+ cups
History of
Cancer:
Me
Relation:
Never
Occasionally
How often do you eat out?
Diabetes:
Me
Relation:
Weekly
Daily
Always
Stroke:
Me
Relation: How many meals do you eat per day?
Heart Disease:
Me
Relation: Do you eat at roughly the same times each day?
Heart Attack:
Me
Relation: Do you ever skip meals?
Depression:
Me
Relation: How many calories do you eat per meal?
Bipolar Disorder:
Me
Relation: How many calories do you eat per day?
Headaches:
Me
Relation: Do you shop with a grocery list?
Constipation:
Me
Relation: Do you plan meals in advance?
Sleep Disorders:
Me
Relation: Do you use sugar or butter substitutes?
Obesity:
Me
Relation: Do you drink diet soda?
When do you feel hungriest?
Overall Health Do you wake up hungry at night?

Great
Good
Fair Do you snack at night?
Rate your overall health

Poor
Bad Do you eat when youre stressed or sad?
How often do you feel
Never
Occasionally Are you currently stressed or sad?
depressed?
Often
All the time Foods you crave:
Foods you dislike:
How often do you
Never
Sporadically
exercise?
Regularly
Daily Exercise
How often do you
Never
Occasionally
Often How many days per week do you work on cardio?
smoke?
Daily
Used to Length of time spent on cardio each session:
How many cigarettes do you have per day? How many days per week do you work on strength?
Length of time spent on strength each session:
How often do you
Never
Occasionally
Often
drink alcohol?
Daily
Used to Injuries/conditions that interfere with exercise:
How many alcoholic drinks do you have per week?
How often do you
Never
Occasionally
Often Other
eat fast food?
Daily
Used to Weight at birth:
How restful is your
Restful
I wake up once or twice Weight 5 years ago:
sleep?
I wake up often
Fitful Weight six months ago:
How many hours of sleep do you get per night? Heaviest weight: Age:
Lightest weight: Age:
Current Medication: Target weight:
Dosage: Eating disorders:
Starting date: Length of time:
Dietary Restrictions: When did weight loss/gain begin?
How often do you have headaches? Do you live with anyone who is overweight?
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