Medical History: Do you have any of the following heath issues:
Diabetes, Stroke, Heart Attack, High Blood Pressure, High Cholesterol,
Other?
List any medications you are taking:
Do you
take vitamins, minerals, herbs or other supplements?
Yes
No
Describe:
Are you allergic to or intolerant to any foods?
Yes
No
Describe:
Do you exercise regularly?
Yes
No
Describe:
List and describe any weight loss plan you have tried in the
past (include dates and lbs. lost):
Why do you want to lose weight?:
What is your ideal weight?:
Has your weight changed recently?:
Yes
No
If yes, how?:
Why has your weight changed?:
What changes do you feel you need to make in the way you are
eating now?:
Who prepares food in your home?:
Where do you eat your meals or snacks at home?:
Kitchen Table
Dining Room
In front of TV
How often do you eat out?:
Where do you usually eat out?:
Fast food
Buffet
CafteriA
Restaurant
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The University of Kansas Medical Center