Please take the time to thoroughly fill out this Questionnaire prior to your Global Assessment Appointment.
First Name Last Name
Address
City State Zip
Phone ( ) Cell ( )
Date of Birth Age Sex Race
Email address
Do you use Social Media Y / N Which ones? Facebook / Twitter / Instagram / Other:
Primary Care physician
Full name: Phone #:
Address:
Additional care providers:
Full name: Phone #:
Address:
Full name: Phone #:
Address:
Emergency Contact
Name: Phone #:
Relationship:
Pharmacy Used for Prescription Medications
Name: Phone #:
Health
Complete the following statement: In general, my overall health is... (circle one)
Poor Fair Good Very Good Excellent
When was your last physical exam? Within the last.... (circle one) Year 2 years 3-4 yrs 5 yrs or more
When did you last have fasting labs completed? Not done
How many days from work did you miss in the last 6 months due to illness or injury?
Have you had any of the following? Please explain any “yes” answers on the back of this sheet.
Condition / Y / N / Condition / Y/ NHigh Blood Pressure / Gallbladder Disease
Heart Disease / Liver Disease
Yellowing / Chest Pain
Thyroid Disease / Irregular Heartbeat
Kidney Disease / Alcoholism or Drug Abuse
Shortness of Breath / Arthritis
Stroke / Cancer
Swelling of feet / Anemia
Frequent Headaches / Low back pain
Seizures or epilepsy / Gout
Psychological Difficulties / Ulcers
Psychiatric conditions / Constipation
Depression / Chronic Diarrhea
Anxiety or Panic Attacks / Heartburn
Hemorrhoids / Gas/Bloatin
Asthma / Chronic Cough
Phlebitis / Allergies
Fainting/light headed / Dizziness
Diabetes / Frequent Nausea
Loss of Muscle Strength / Numbness in hands/feet
High Cholesterol / Sleep difficulties
Other
Current Medications: (list all, including name, frequency and dose. Include hormones, birth control pills and vitamins).
Please list any medication allergies:
Energy Use a 0-10 scale where 0 = no energy and 10 is very high energy.
During a typical work week, what is your energy level on most days?
On a typical weekend day, what is your energy level?
Exercise
Regular physical activity - Do you currently participate in regular physical activity? Yes / No
*Aerobic exercise - How many days per week do you engage in aerobic exercise of at least 20 minutes duration (walking, cycling, jogging, swimming, aerobic dance, active sports)?
*Strength exercises - How many times per week do you do strength building exercises for 20 minutes or more, such as sit-ups, pushups, group classes such as boot camp or use strength training equipment?
*Flexibility or stretching exercises - How many times per week do you do stretching exercises or yoga for five minutes or more to improve flexibility of your back, neck, shoulders, and legs?
Any Current limitations on physical activity (e.g. injuries, illness, medical conditions):
Previous limitations on physical activity (over the last 5 years):
Interests: (please circle all that are interesting to you)
Yoga Dance Free weights Tennis Outdoor walk/jog
Pilates Aerobics Weight machines Hiking Competitive sports
Elliptical Video tapes Calisthenics Group classes Exercise Ball
Stationary bike Swimming Personal Training Skiing x-country skiing
Cycling outside Tai Chi Seated exercises Treadmill Resistance bands
Other
Bodily Pain
How much bodily pain have you had during the past four weeks? (please circle)
Very severe Severe Moderate Mild Very mild None
Rate how important regular physical activity is to you: 1 (low) - 10 (high)
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Your readiness to make changes to reach or sustain regular physical activity: Please circle one.
1. I am already sustaining regular physical activity (6 mos. +)
2. I recently started working on this
3. I am planning a change this month
4. I am planning a change to start in the next 6 months
5. I have no present interest in making a change
Nutrition
What 1 or 2 things would you like to change about your diet?
Do you read food labels? Y / N. If yes, what do you look for?
When and what do you usually eat over the course of a typical day?
Write NONE if you do not eat that meal or snack
Meal / Time / Foods EatenBreakfast
Snack
Lunch
Snack
Dinner
Snack
How many times do you graze/snack per day?
Do you eat before going to bed? Y / N What do you eat?
How many ounces of water do you drink each day?
What food habits would you like to change?
Who plans meals? Who cooks? Who Shops?
Which foods do you crave the most?
Do you eat while watching TV? What do you eat?
Screen Time (TV, Computer, electronics) Hrs/day Time of day
Please record your major diets which resulted in weight loss
Diet / Age / Weight at start of diet / Pounds Lost / Comments1
2
3
4
How many times have you intentionally lost 20 lbs. or more and then gained it back?
Never Once or twice 3-4 Times 5 times or more
If you have been pregnant, please tell us about your weight experience during and after pregnancy:
Family History of Overweight
Degree of OverweightRelative / Age / None / Slight (5-15lbs) / Moderate (16-49 lbs) / Very (50+ lbs)
Mother
Father
THE FOLLOWING QUESTIONS ASK ABOUT YOUR EATING PATTERNS AND BEHAVIORS WITHIN THE LAST 3 MONTHS. FOR EACH QUESTION, CHOOSE THE ANSWER THAT BEST APPLIES TO YOU.
1. During the last 3 months, did you have any episodes of excessive overeating (i.e., eating significantly more than
what most people would eat in a similar period of time? Yes No
NOTE: IF YOU ANSWERED “NO” TO QUESTION 1, YOU MAY STOP. AND GO TO THE NEXT PAGE.
2. Do you feel distressed about your episodes of excessive overeating? Yes No
Within the past 3 months......
3. During your episodes of excessive overeating, how often did you feel like you had no control over your eating (e.g.,
not being able to stop eating, feel compelled to eat, or going back and forth for more food)?
Never/Rarely Sometimes Often Always
4. During your episodes of excessive overeating, how often did you continue eating even though you were not hungry?
Never/Rarely Sometimes Often Always
5. During your episodes of excessive overeating, how often were you embarrassed by how much you ate?
Never/Rarely Sometimes Often Always
6. During your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterward?
Never/Rarely Sometimes Often Always
7 . During the last 3 months, how often did you make yourself vomit as a means to control your weight or shape?
Never/Rarely Sometimes Often Always
In general, during the past 6 months, how important has your weight or shape been in how you feel about yourself as a person (as compared to other aspects of your life, such as how you do at work, as a parent, or how you get along with other people)?
Not very important Somewhat important Very important
During the past 6 months, how upset were you by overeating (eating more than you think is best for you?)
Not at all Slightly Moderately Greatly Extremely
Have you attempted any of the following behaviors in order to prevent gaining weight?
Taking more than twice the recommended dose of diet pills / Y / NTaking more than twice the recommended dose of laxatives / Y / N
Taking more than twice the recommended dose of diuretics / Y / N
Vomiting after eating / Y / N
Abstaining from food for more than 24 hours / Y / N
Exercising excessively / Y / N
Rate how important reaching and sustaining a healthy weight is to you: 1 (low) – 10 (high)
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Your readiness to make changes in order to reach and sustain a healthy weight
1. I am already maintaining a healthy weight (6 mos. +)
2. I recently started working on this
3. I am planning a change this month
4. I am planning a change to start in the next 6 months
5. I have no present interest in making a change
Lifestyle
Do you smoke cigarettes? Yes No If yes, # per day
Do you drink alcohol? Yes No If yes, type and amount of alcohol per week
Are you currently seeing a mental health professional? Yes No
If yes, please provide name and contact info:
Have you experienced abuse or trauma (physical, emotional or sexual)? Yes No
Marital or Relationship Status
Number of Children and ages:
Highest grade/college year completed Occupation
What hours do you usually work? How long in this occupation
Are you satisfied with your job/career? Not at all Slightly Moderately Greatly Extremely
Has your weight caused you problems at work? (please explain)
Has your weight caused you problems at home? (please explain)
What do you typically do in your free time?
Is your family supportive of your weight loss efforts? If yes, how?
Is anyone likely to sabotage your efforts? If yes, how?
What do you attribute your weight problems to?
Stress and Mental Health
How well do you feel you are coping with your current stress load?
Unable to cope / Having trouble coping / Trouble coping at times / Coping fairly well / Coping very well
Rate your stress level on a scale from 0-10:
0 no stress 1 2 3 4 5 average stress 6 7 8 9 10 maximum stress
What is the most significant source of stress at this time?
What have you found to help with this stress?
For each question in the table below, please give the one answer that comes the closest to the way you have been feeling in the last four weeks.
1 = None of the time
2 = A little of the time
3 = Some of the time
4 = A good bit of the time
5 = All of the time
How much of the time during the past four weeks ...
a. Have you felt calm and peaceful? / 1 / 2 / 3 / 4 / 5b. Did you have a lot of energy? / 1 / 2 / 3 / 4 / 5
c. Have you been a happy person? / 1 / 2 / 3 / 4 / 5
d. Did you take the time to relax and have fun daily? / 1 / 2 / 3 / 4 / 5
e. Have you felt downhearted or blue? / 1 / 2 / 3 / 4 / 5
f. Have you felt worthless, inadequate or unimportant? / 1 / 2 / 3 / 4 / 5
If you answered 3 or higher to question e (Have you felt downhearted or blue) or question f (Have you felt worthless, inadequate or unimportant) in the previous section, please complete the following:
A = None or little of the time.
B = Some of the time.
C = Most of the time.
D = All of the time.
Been feeling low in energy, slowed down? / A / B / C / DBeen blaming yourself for things? / A / B / C / D
Had a poor appetite? / A / B / C / D
Had difficulty falling asleep, staying asleep? / A / B / C / D
Been feeling hopeless about the future? / A / B / C / D
Been feeling no interest in things? / A / B / C / D
Been feeling blue? / A / B / C / D
Thoughts about or wanted to commit suicide? / A / B / C / D
Had difficulty concentrating or making decisions? / A / B / C / D
What is one thing in your life you would like to accomplish/complete and why? (other than to lose weight)
Think back on other weight loss attempts. How are you most likely to sabotage your efforts, both short term and long term?
Is there any additional information that would be helpful to us to know when developing your individualized lifestyle and weight management plan?
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