Nutrition History and Questionnaire
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1 Nutrition History and Questionnaire Florida Surgical Weight Loss Center Last Name: First Name: Address: address: DOB: Occupation: Highest Education Level Completed: Grade School High School College Graduate Degree Surgery Type: AP Laparoscopic Band Placement Gastric Sleeve Surgeon: Anticipated date of surgery (if known): Medical History (please check all that apply) Arthritis Cancer Type: Depression Eating Disorder Gastric Reflux Heart Disease High Blood Pressure High Cholesterol High Triglyceride Level Hyperthyroidism Hypothyroidism Kidney Disease Lupus Multiple Sclerosis Orthopedic surgery Shortness of Breath upon Exertion Sleep Apnea Type 1 Diabetes Type 2 Diabetes Other Please list any food allergies or intolerances: Why do you want to lose weight?
2 What are some of the things that have kept you from accomplishing weight loss? Who would you consider your support persons during this process? Height: Weight: What is your goal weight? What is the most you have weighed (in your adult life) and at what age? What is the lowest you have weighed (in your adult life) and at what age? Past Attempts at Weight Loss (please be as specific as possible): Weight Watchers Jenny Craig Nutrisystem Optifast SlimFast Atkins Zone Diet HCG Diet South Beach Diet Overeaters Anonymous Paleo Diet Hypnosis
3 MediWeight Loss Physician-supervised Diet Dietitian-prescribed Diet Cleanse/Detox Diet Any other fad diet Elaborate: Self Diet Elaborate: Reason for Stopping Program Have you ever taken prescription or over-the-counter medications for weight loss, suppression of appetite or other dieting reason? If yes, please indicate below: Have you ever attended a weight-loss retreat, rehab, or spa? If so, please indicate below: Reason for Stopping Please provide details of any previous surgeries or other weight-loss measures you have undergone that were not previously mentioned: Please list all vitamins, herbs or other dietary supplements you take and how often:
4 How many times per week do you typically fast food? times per week How many times per week do you eat out at dine-in restaurants? times per week Please list the names/types of the restaurants at which you tend to eat (ex: McDonald s, BBQ, Chinese takeout, etc.): How many meals are prepared and d at home? meals How many times do you sweets? Please list the types of sweets you and how often: (ex: cookies, ice cream, chocolate, donuts, etc): How many times do you Soda? Never >5 Diet Soda? Never >5 100% Fruit Juice? Never >5 Tea? Never >5 Sweet Tea? Never >5 Fruit-flavored drinks? Never >5 Coffee? Never >5 What do you usually add to your coffee? Water? Never >5 Please check the condiments that you usually at least per week or more: Butter Mayonnaise Olive Oil Margarine Oil-based Salad Dressing Cream-based Salad Dressing Canola Oil Mustard BBQ Sauce Tabasco Sauce Whipped Cream Syrup Honey Agave Nectar Other; please specify: How many times do you vegetables? vegetables What are your favorite types of vegetables to?
5 How many times do you fruits? fruits What are your favorite types of fruits to? How many times do you meat? meat What are your favorite types of meats to? If you are a vegetarian or vegan, what are your sources of protein in your diet? Do you alcohol? Yes No If yes, how often? Never per week per week Daily What type of alcoholic drinks do you usually? Beer Wine Liquor Mixed Drinks Do you smoke? Yes No If yes : pack(s) Please indicate which dieting barriers apply to you most: Portion sizes Stress eating Not feeling full Lack of knowledge Snacking regarding healthy Late night hunger foods or diets Binge eating Financial barriers Emotional eating Temptations within household Work schedule Other; please specify: Do you exercise? Yes No If yes, please list the types of physical activity below: Physical Activity How Many Times Per Week How Many Minutes If no, please describe any physical disabilities or other reasons that would prevent you from participating in a fitness routine:
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