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Weight Assessment
Name
Your answer
Date
MM
/
DD
/
YYYY
Age
Your answer
Height
Your answer
Current Weight
Your answer
Highest Body Weight
Your answer
Lowest Body Weight in the last 5 years
Your answer
Has your weight changed in the past 12 months?
Yes
No
Clear selection
Have you gained or lost weight in the past 12 months?
Yes
No
Clear selection
Have you gained or lost weight in the past 12 months?
Yes
No
Clear selection
How much has your weight changed in the past 12 months?
Your answer
Please explain why you think your weight has changed in the past 12 months?
Your answer
In your opinion, can you lose weight easily or is it challenging for you to lose weight?
Easy to lose
Challenging to lose
Clear selection
In your opinion, is it challenging for you to keep weight off once you have lost it?
Yes
No
Clear selection
If it is challenging for you to keep weight off you have lost, what makes it especially challenging for you?
Your answer
What commercial programs have you done in the past in order to lose weight?
Your answer
Have you been a recipient of any bariatric procedures?
No
Yes
Clear selection
If so, What bariatric procedures have you had in the past in order to lose weight?
Your answer
What herbal, supplement, or prescription medications have you used in order to lose weight?
Your answer
What has been your most successful attempt at losing weight?
Your answer
How long did you keep the weight off?
Your answer
How much of the weight did you keep off?
Your answer
How quickly did you gain the weight back?
Your answer
What is your goal weight?
Your answer
How long do you think it will take for you to reach your weight goal?
Your answer
What things do you plan to do differently than in the past to keep you within 5-10 pounds of your goal weight once you reach it?
Your answer
On a scale of 1-10 how motivated are you to make permanent changes in the foods/beverages you consume?
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4
5
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7
8
9
10
Clear selection
On a scale of 1-10 how motivated are you to engage in more activity/exercise if recommended to meet your weight goals?
1
2
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8
9
10
Clear selection
On a scale of 1-10 how willing are you to prepare and eat more of your meals at home if recommended to meet your weight goals?
1
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9
10
Clear selection
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