IDENTIFYING INFORMATION

People who want to achieve long-term weight control need to spend at least 30 minutes a day, for a minimum of 6 months, trying to change their eating, exercise, and thinking habits.

Do you ever eat large amounts of food and stop only because of the following:

Weight Loss Attempts: Make a list of the diets, medications, and/or other measures you have tried, how old you were when you tried them, when you tried each one, how much weight you lost, the length of time the weight stayed off, and how much weight you gained back.

Indicate if you have had or have any of the medical conditions listed below:

List all medications (including any over the counter, herbal, natural) that you take regularly and for what:

During the past year:

MENTAL HEALTH HISTORY

List any counseling services that you have received which may include individual, group, or marital therapy:

PSYCHOSOCIAL INFORMATION

List your children/step-children's age and sex, and indicate whether they are overweight, average, or underweight. Include any children from previous relationships, whether they are living with you or not.

Describe your parents' weights while you were growing up:

Describe your parents' weights throughout your adulthood: