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Jeffrey Rose, CMH
Franka Fiala, CH
Elena Beloff, CH
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Weight Loss Form
Name (First then Last):
Sex:
Male
Female
Date of Birth:
...
Marital Status:
Single
Married
Divorced
Partnered
Separated
Widowed
Mobile Phone:
Address:
Other Phone:
Profession:
Email:
Employer:
Who referred you to our center?
Referral–from a doctor
Referral-from former client
NY Smoker’s Quit Line
Recover Magazine
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Google Main Site
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Yahoo Local
Psychiatry Today
Other web search
Physician’s Name/Practice
Date of Last Visit
...
Has your doctor recommended losing weight?
Yes
No
Do you have a gym membership?
Yes
No
Height
Weight
At what age did you start significant weight gain?
List three of your best reasons to lose weight:
What methods have you tried previously?
What reasons do you consider being the most relevant why you carry extra weight?
Do you have any heredity health problems, emotional coping childhood experience, bad habits or any other reasons?
When are you most likely to overeat?
What is your greatest problem food(s) (craving for)?
Can you identify one or two beliefs that you consider to be self-sabotaging or self-critical? (Things you say to yourself)?
List clues that you are losing weight besides the scale.
List three things you look forward to upon arriving at your desired weight?
Do you have any health problems or concerns that might be related to weight gain?
What other health concerns do you have?
Please list medications taken on a regular basis.
Allergies:
Boredom:
1
2
3
4
5
6
7
8
9
10
Unconscious Easting:
1
2
3
4
5
6
7
8
9
10
Confidence Eating From Stress
1
2
3
4
5
6
7
8
9
10
Eating From Stress:
1
2
3
4
5
6
7
8
9
10
Overeating:
1
2
3
4
5
6
7
8
9
10
Reward:
1
2
3
4
5
6
7
8
9
10
Snacking
1
2
3
4
5
6
7
8
9
10
Sodas:
1
2
3
4
5
6
7
8
9
10
Alcohol
1
2
3
4
5
6
7
8
9
10
Sweets/Sugars:
1
2
3
4
5
6
7
8
9
10
What did you eat yesterday for:
Is typical?
Yes
No
When do you typically finish your dinner?
Who in your life is important to you? Why?
Excersise?
Sedentary (No exercise)
Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Caffeine
None
Coffee
Tea
Cola
# of cups/cans per day?
How many alcoholic drinks per week?
Are you concerned about the amount you drink?
Yes
No
Do you smoke?
Yes
No
Do you have trouble falling asleep?
Yes
No
Do you have trouble staying asleep?
Yes
No
Do you wake feeling unrested?
Yes
No
How much water do you typically consume in a day?
0-1 bottles
2-3 bottles
1 quart more
Is there a time of day that eating seems to be harder to control than others?
Yes
No
Do you normally reach for food simply for the taste?
Yes
No
Do you associate socializing with eating?
Yes
No
Do you eat more when alone? Using food for companionship?
Yes
No
Do you eat more when you are sad?
Yes
No
When you eat, are you always hungry?
Yes
No
Do you have set times or habits when you eat?
Yes
No
How many bowel movements do you have daily:
1
2
3
4+
not sure
less then 1 daily
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