weight loss questionnaire pdf

Please answer the following questions as honestly as possible. 2. How long have you been considering weight loss surgery? L. Beechy et al. Center for Weight Management and Bariatric Surgery Lowell General Hospital Center for Weight Management and Bariatric Surgery, 20 Research Pl, N. Chelmsford, MA 01863, Tel 978-788-7201 (Weight Watchers, Jenny Craig, etc.) These can confirm what information to gather. You can print out and complete all of the required forms before your first visit to the office to provide a faster, more effective hypnosis experience. Think about your previous efforts, starting with the first one, whether in childhood or adulthood. optifast, juicing) diet pills: meridia, xenical Please record your major weight loss efforts, (e.g., diet, exercise, medication, etc.) For each question, circle the number that best describes your attitude, then write the number of your answer on the line before each question number. A good weight loss plan consists of combining a well-balanced diet with five days of moderate to intense cardiorespiratory exercise and 2-3 days of resistance training. When you start your program, make sure you have some baseline measurements such as your weight, body-fat percentage, and circumference measurements. PDF. Patient Information Name Date of Birth Gender (circle one) Male - Female Address / City / State / ZIP Obesity is a chronic disease, which requires a lifelong treatment. On a scale of 0 (not confident) to 10 (very confident), choose ONE number that reflects how confident you feel now about being program/plan results? This questionnaire must be completed and returned prior to scheduling your first appointment. If you are thinking about losing weight, trying to lose weight, in the process of losing weight, or struggling to lose weight -- please take this short survey. Weight Loss Program Questionnaire Survey. What did you learn from these programs regarding your weight… 15 Diet Questionnaire Examples in PDF. Distributor Weight Loss Challenge RULES AND GUIDELINES SECTION ONE: Distributor Weight Loss Challenge Rules and Guidelines *Amount is in U.S. dollars. 2820 Ohio Street / Augusta, KS 67010 phone: (316) 775-7500 fax (316) 775-3685 Page 2 - Weight Loss Questionnaire 13. When used in tandem with a Weight loss calculator, it helps you scientifically plan and measure your progress as you work towards a healthier body.A weight loss chart can schedule and tabulate all your activities. You will be helping me include vital information for my readers in my soon to be released weight loss book. For people with BMI of 35 or greater, surgical therapy leads to dramatic reductions in weight of 20 kg or more. FRAIL Questionnaire assesses five components: Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight and creates an acronym to facilitate utilization (FRAIL). We are looking for participants 18-60 years old with a BMI over 27 kg/m2 in this 2.5-year fully online study. Please check all previous programs you have tried in order to lose weight. Name Date of Birth Physician Information Referring Physician / PCP (Name) Location (city, state) Date of last visit Date of next visit 3. Occupation/Work Schedule: _____ Diet History (types you've been on/results/lasting power): _____ ... weight loss are not FDA approved for weight reduction and/or treatment of obesity. The Weight Efficacy Life-Style Questionnaire (WEL) and the International Physical Ac-tivity Questionnaire (IPAQ) assessed self-efficacy and physical activity for 124 volunteers aged 17–61. GENERAL INFORMATION Why are you seeking a weight loss program? This is the WEIGHT LOSS icon. The YMCA of Burlington County and Lourdes Health System (consisting of Our Lady of Lourdes Medical Center, Lourdes Medical Center of Burlington County and the Lourdes Wellness Center) are considering a joint program to support the weight loss goals of individuals in the communities we serve. Centra Weight Loss Clinic Initial Appointment Questionnaire *Please note: To provide appropriate care forms MUST be complete prior to your initial visit. SECTION E: WEIGHT LOSS HISTORY 1. How do you feel about the way you look at this weight (circle one)? Please record any major weight loss efforts (i.e., diet, exercise, moderation, etc.) Weight History Dietary History The information requested in this questionnaire is very important. Yes No 12. BOX 1 CHECK ITEM WHQ.499: IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’) IN It suggests different actions and activities to promote weight loss. 2. Bariatric and Metabolic Weight Loss Center Weight Loss Program Questionnaire: Please complete this questionnaire and bring it with you to your appointment with the practitioner. Yes No If yes, how long? which resulted in a weight loss of 10 pounds or more. Diet Program Number of Months How much weight did you lose? Methods: Athletes (607 males and 215 females; age = 19.3 T 5.3 yr, weight = 70 T 7.5 kg, height = 170.6T 9.8 cm) completed a previously validated questionnaire developed to evaluate rapid weight loss in judo athletes, which provides a score. Obesity is a disease process with a physiological cause, like diabetes or hypertension. Weight loss tables Alternative measurements when BMI cannot be obtained by measuring weight and height. The Weight-Efficacy Lifestyle Questionnaire Short Form (WEL-SF) In 2012 a short version of the original WEL ( Clarketal.,1991 ) was developed — from 20 questions and 5 situational components to 8 questions and 1 situational component How does your current weight make you feel? Weight Questionnaire (Complete this page only if you are interested in weight loss or weight gain) 1. There are a lot of diets and there are also a lot of reasons behind those diets. A weight loss chart is a simple but effective planner to help keep track of your weight. SECTION E: WEIGHT LOSS HISTORY 1. 3. I ask these questions so I can really get a feel for who you are and what makes you tick. Medical Weight Management Program Pre-Program Questionnaire As part of our medical clearance, we need certain information about your health. Long-term Weight Loss. Please be thorough. Step 1: Outline the Survey Objectives and Modules to Use. Weight Loss Questionnaire 1. WEIGHT LOSS QUESTIONNAIRE Please give us some brief information about yourself and your weight loss goals. Yes No If yes, how much weight did you lose? what weight loss programs have you participated in? Quick Weight Loss Center Diet. Summary: The diet is low in sodium, fat, sugar, and carbs, and high in protein. It is structured so that you enjoy small, frequent meals (I eat three meals/day and enjoy two to three snacks between meals). If you’re willing to spend time developing new eating and activity patterns over the next several months, there’s good chance this program is for you. Office Phone: 989-272-3215 3069 Bay Plaza Drive, Saginaw, MI 48604 wiseweightmd@gmail.com. This information will assist us in your care plan. LBS 3. In the following text and in Table 1 are summaries of the five items from the FRAIL Questionnaire, the sources (instruments) from which we obtained information/data, ... Have you maintained any weight loss for up to 1 year at any of these programs? Email: Send to WeightLossSurgery@urmc.rochester.edu. It indicates a choice needs to be made in order to promote healthy weight loss. weight watchers jenny craig slim fast atkins south beach la weight loss nutrisystems lindora overeaters annonymous liquid diets (eg. Size: 114.4 Kb. / … Centra Weight Loss Clinic Initial Appointment Questionnaire *Please note: To provide appropriate care, forms MUST be complete prior to your initial visit. It is not a result of “weakness” or “lack of willpower” on the part of the patient. Think about the amount of weight you want to lose. Weight Efficacy Lifestyle Questionnaire Short-Form (WEL-SF) Read each situation below and decide how confident (or certain) you are that you will be able to resist overeating in each of the difficult situations. _____ 2. _____ How long did you keep it off?_____ Have you ever tried your own plan or diet for weight loss? Purpose: To identify the prevalence, magnitude, and methods of rapid weight loss among judo competitors. Nutritional Coaching Client Questionnaire. length of participation? _____ Weight History 2. Culture E-Fitness Questionnaire Template. Most people have difficulty maintaining weight loss long-term. Thank you. Weight Loss Programs * 1+3= * If you are a human seeing this field, please leave it empty. that resulted in a weight loss of 10 pounds or more. There are diets that mainly focus on losing weight, others gaining weight, while others do it to maintain a healthy lifestyle in order to live a long and healthy life. Describe your present weight (circle one): Very overweight/Obese Slightly overweight Healthy Weight Underweight 2. Schedule An Appointment Today! Date_____ Name_____ 1. Have you ever tried structured programs to lose weight? We are running a study to evaluate long-term weight loss and other outcomes (e.g., quality of life). Add the PDF you want to work with … Nutritional Therapy Questionnaire Please provide details as fully and accurately as possible. What are your goals about weight control and management? Clinical Therapeutics, 24(4), 690-700. The Weight Loss Readiness Test II NAME: Answer the questions below to see how well your attitudes and current behaviors equip you for a weight loss program. Nutrition Questionnaire Please bring the form with you on your initial clinic visit. In order to add an electronic signature to a weight loss questionnaire, follow the step-by-step instructions below: Log in to your signNow account. Yes No Were you successful? Please refer to The ‘MUST’ Explanatory Booklet for more information when weight and height cannot be measured, and when screening patient groups in which extra care in interpretation is needed (e.g. 6/22/10 Questionnaire: MEC WHQ-1 WEIGHT HISTORY – WHQ Target Group: SPs 8-15 years . Before selecting the modules to use within the survey, the survey manager(s) ought to outline the survey’s objectives and therefore the project’s survey population. A new approach to multicultural item generation in the development of two obesity-specific measures: the Obesity and Weight Loss Quality of LIfe (OWLQOL) questionnaire and the Weight-Related Symptom Measure (WRSM). As you compete each of We keep all information confidential. Weight Loss Questionnaire This form is to be completed during or prior to your initial consultation. Everyone wants to lose weight instantly, but in this program you will lose weight gradually. Client Forms for all new Austin Hypnotherapy clients. Make the Choice to Lose Weight and/or Body Fat This is the CHOICE icon. Weight reduction of 5% to 7% body weight is associated with lower ˜ Past 30 days ˜ Past 48 hours Point Scale 0 – Never or almost never have the symptom ... ˜No Dairy ˜No Wheat ˜Weight Loss ˜Other _____ Which meals … Tlo give you the best care we must have complete answers. alternativeoptionscoaching.com. Name: Current Height: Current Weight: Goal Weight: 1. Step 8: Weight Loss Diets Only document your weight loss attempts in the past 5 years. Weight on Quality of Life, the Impact of Weight on Quality of Life — Lite, the Moorehead–Ardelt — II, the Weight Related Symptom Measure, the Obesity and Weight Loss Quality of Life questionnaire, and the Obesity Related Well Being questionnaire. THE FIRST SESSION Thank patient for completing the health questionnaire Share personal passion, credentials and experience Create health goals and weight loss/wellness vision with patient Please print. If a question does not apply to you, answer with N/A. Date Name Medical Record Number Address 1 Phone Number Address 2 e-mail 1. We look forward to supporting you in your journey to better health through weight loss. The questionnaire below contains some personal questions. NUTRITION ASSESSMENT QUESTIONNAIRE Welcome to Deaconess Weight Loss Solutions. Please answer all of the following questions. • The Weight Loss Challenge Manual, MyHerbalife.com support materials, and Herbalife’s Weight Loss Challenge website for participants (HerbalifeWLC.com) are based on a 12-week program. It identifies idea, actions or facts related to weight loss. Why do you want to lose weight? Dieting and Weight Loss Survey. List any physician-supervised and documented weight loss attempt: List any other diets and/or weight loss methods you’ve tried: Medical Spa Medical Weight Loss This is the ACTION icon. Both counseling-based and drug-based maintenance interventions were helpful in retaining weight loss. Review the questionnaire to assess stages of readiness and areas to build on Note concerns Formulate initial strength based questioning . effective in reducing mean weight by about 3 to 5 kg. Weight Loss Questionnaire. Take time to think over your previous efforts, starting with the first one, whether in childhood or adulthood. What’s the main reason you are seeking treatment at this time? What is your current weight? You may have difficulty If at any time you need more space please continue on a separate sheet. 2. Weight Loss Questionnaire The Thinnergy Philosophy 1. Eating fruits and vegetables is an important part of healthier eating habits. Drinking water instead of high calorie drinks like soda can help people lose weight. Walking more often is a good way to lose weight. In order to lose weight, caloric input needs to be less than caloric output. [$175 for 2.5 years, remote/online.] If you haven’t made one yet, you can, through Google or Facebook. Step 2: Choose Queries. A healthy weight loss plan is about making lifestyle changes. All diets may help you lose but it is rare that you see people maintain that weight loss without learning what to eat, what not to eat, how to eat, how often to eat, portion control, and getting and staying active to burn those calories. recent or somewhat severe health symptoms, please indicate that you will fill out the questionnaire for the past 48 hours. What is your desired goal weight …