Beruflich Dokumente
Kultur Dokumente
Name:
Occupation:
Phone Number:
Email:
Address :
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Age :
yrs.
Gende
r:
Height :
cm
Weight :
kg
BMI :
%
BMR :
kcal
Very Overweight
Very Overweight
Triggers of weight gain: in your opinion, which factors are the most
important causes of your weight gain?
Pregnancy
Stopping smoking
Family history of obesity
Change in activity level (describe):
______________________________________________________________________________
Emotional factors (describe) :
______________________________________________________________________________
Medicines (describe):
______________________________________________________________________________
Other events or factors (describe):
______________________________________________________________________________
Please answer the following questions regarding your lifestyle:
On average I get ______________hours of sleep per night.
My work hours are: __________________________________________
Prior Weight Loss Efforts
I start dieting at age: ____________________
Have you lost weight and regained weight many
yes
no
sometim
times?
es
After losing weight do you gain even more back?
yes
no
sometim
es
Diet History: Below is a list of different diet programs. Please indicate
which of these methods you have tried, if any:
Diet or
What age
Number of
How much
How much
Program
were you
times on this weight did
weight did
when you
diet
you lose the you lose the
first tried
first time?
second
this diet?
time?
Commercial
Programs:
Bodykey
Shaklee
Cambridge
Herbalife
Diet Centre :
Others (please
list)
Medically
Supervised
Liquid
Diets :
Medication(s
):
Fat burner
Fat blocker
Carbohydrate
Blocker
Supplement :
Varies
Dinner
1 time/week
2-3 time/week
>4 time/week
Convenience
2-3 time/week
>4 time/week
Business
Social
Convenience
2-3 time/week
>4 time/week
Convenience
RM 15 -20
>RM 20
How much portion of Carbohydrates, Protein, and Fibre for each meal? (List type
and average number of serving)
Meal
Carbohydrates (scoop) Protein (amount)
Fibre
(scoop)
Breakfast
Midbreakfast
Lunch
Tea
Dinner
Supper
How often do you usually have any of these beverages?
Juice
None
1-2 /day
3-5 /day
Soda (non-diet) None
1-2 /day
3-5 /day
Soda (diet)
None
1-2 /day
3-5 /day
Coffea and/or
None
1-2 /day
3-5 /day
tea
Fruit smooties
None
1-2 /day
3-5 /day
Milk-based
None
1-2 /day
3-5 /day
drinks
(latte,frappucin
o,etc.)
>6
>6
>6
>6
/day
/day
/day
/day
>6 /day
>6 /day
How often did you have a drink containing alcohol in the past year?
Never Monthly or
Once a week
2-4 times/week 4 or more times/week
less
In the past year, on a typical day when you were drinking, how many
drinks would you have?
None
5-6
7-9
>10
In the past year, how often did you have 5 or more drinks on one occasion?
Never <Monthly
Monthly
Weekly
2-4 times
Daily
weekly
Cigarette use:
None
<
packs/day
-1
packs/day
>1 packs/day
Quit____years ago
Cohabitating
Separated
Remarried (2nd,3rd,4th)
Compulsive
Disorder
Alcohol
dependent
Drug
dependence
Schizophrenia
Diabetes
Heart Disease
Stroke
Obesity
High Blood Pressure
Thyroid problems
High choloestrol
Substance abuse disorder
Eating disorder
(anorexia,bulimia)
Other psychological
disorder
Cancer
Others
Your Medical Conditions
Pulmonary
Smoked within the past year
Ye
s
N
o
Ye
s
N
o
Ye
s
N
o
Ye
s
N
o
Require oxygen
Had a Pulmonary Embolism/Blood clot in lung
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Use CPAP/BiPAP
Gastrointestinal
Heartburn requiring medication
Gallstones or had your gallbladder removed
Pancreatitis
Fatty Liver Disease
Previous weight loss surgery
Musculoskeletal
Back pain
Disc Disease in the back
Rheumatoid arthritis
Osteoarthritis
Musculoskeletal Disease
Limitation of activity by pain
Daily pain medication required
Surgery for joints planned
Mobility devices used (cane, walker,etc)
Renal/ Kidney
Kidney Disease
Kidney failure requiring dialysis
Urinary or stress incontinence
Kidney stone
Cardiac / Vascular
Heart attack
Ye
s
N
o
Ye
s
N
o
Ye
s
N
o
Ye
s
N
o
I prefer to use:
Cash (Yes/No)
Debit card (Yes/No)
Credit Card (Yes/No) :(Please list name of Credit
card)________________________________
++(Very
High)
>39
>40
>42
>25
>28
>30
++(Very
High)
>18
++(Very
High)
15- 30
++(Very
High)
>35.4
>35.2
>35
>44.1
>43.9
>43.7
Obese
>30