Tel: 304. 388. 4965
Fax: 304. 388. 4968
Dietary Questions
| 1. Weight history |
| When did you have problems with your weight first? ____________________________________________________ |
| When did you begin to worry about your weight? _______________________________________________________ |
| Why did you start to worry about your weight?_________________________________________________________ |
| Why do you think you are overweight?________________________________________________________________ |
| _______________________________________________________________________________________________ |
| Which members of your family are overweight?_________________________________________________________ |
| What was your lowest adult body weight? Age__________ Weight___________pounds |
| What was your heaviest adult body weight? Age__________ Weight__________ pounds |
| What was your most weight loss? __________pounds. After what?_____________________________________ |
| When you have regained your lost weight, why do you think this occurred? |
| _______________________________________________________________________________________________ |
| _______________________________________________________________________________________________ |
| What do you fee are your barriers to keep your weight off? |
| ___Lack of motivation ___Lack of knowledge about nutrition ___No support (family/friends) ___Time issues |
| ___Others______________________________________________________________________________________ |
| 2. Dietary history |
| How many meals do you have per day?_______________________________________________________________ |
| Do you frequently skip meals? ___Yes ___No |
| If you answered Yes, which meal(s) do you skip most frequently? And why? |
| _______________________________________________________________________________________________ |
| Who plans the meals?____________ Who cooks?____________ And food shopping?_________________________ |
| How many time do you eat out per week? _________ |
| Which meal(s) do you eat out most frequently? ___Breakfast ___Lunch ___Dinner |
| How often do you snack between meals? ___0 to 1 ___2 to 4 ___5 to 7 ___Other |
| What do you snack on? ___________________________________________________________________________ |
| List your food cravings (candies, chocolate, fried foods, ice cream, starches, sweets, etc) |
| _______________________________________________________________________________________________ |
| Do you drink during your meal? ___Yes ___No Do you drink alcoholic beverages? ___Yes ___No |
| How many drinks per week? _______________ What type of drinks? __________________________________ |
| Do you smoke? ___Yes ___No If Yes, how many cigarettes per day? ________________________________ |
| Do you drink caffeinated coffee? ___Yes ___No How many times a day? _______________________________ |
| Do you drink caffeinated tea? ___Yes ___No How many times a day? _______________________________ |
| Do you take vitamin, mineral or nutritional supplements? ___Yes ___No |
| If Yes, please list them. ___________________________________________________________________________ |
| _______________________________________________________________________________________________ |
| Are you participating in any type of special diet or eating plan? ___Yes ___No |
| If Yes, please list them. ___________________________________________________________________________ |
| 3. Dietary habits |
| What triggers you to eat? ___Hunger ___Anger ___Depression ___Loneliness ___Lack of control |
| ___Boredom ___Family gatherings ___Social situations |
| How often do you overeat or binge at meals/snacks? ____________________________________________________ |
| Do you ever feel compulsive about foods? ___Yes ___No |
| Do you achieve feeling of fullness? ___Yes ___No |
| 4. Post-surgical commitment |
| What changes do you think you need to make your weight loss surgery successful? |
| _______________________________________________________________________________________________ |
| _______________________________________________________________________________________________ |
| _______________________________________________________________________________________________ |
| How motivated and committed are you to make necessary life-style and dietary changes after your surgery? |
| _______________________________________________________________________________________________ |
| _______________________________________________________________________________________________ |
| 5. Food allergies |
| __________________________________________________________________________ |
| __________________________________________________________________________ |
| 6. Food dislikes |
| __________________________________________________________________________ |
| __________________________________________________________________________ |
| __________________________________________________________________________ |