When did you first notice that you were gaining weight?

Did you ever gain more than 20 pounds in less than 3 months? Y / N If so, when?

How much did you weigh: one year ago?

Life events associated with weight gain (check all that apply): Marriage Pregnancy Night Shift work Injury Drugs Medication (please list:

Previous weight-loss programs (check all that apply): Weight Watchers Nutrisystem

Have you ever taken medication to lose weight? (check all that apply): Phentermine (Adipex) Phendimetrazine (Bontril) Topamax Bupropion (Wellbutrin)BelviqQsymia

How often do you eat breakfast? Number of times you eat per day: Do you get up at night to eat? Y / N List any food intolerances/restrictions: Food triggers (check all that apply):

days per week at What beverages do you drink? If so, how often?

minutesNumber of times per week:

Past medical history (check all that apply): Angina High blood pressure High cholesterol High triglycerides Infertility Glaucoma Cancer (type/s): Have you ever been diagnosed with an eating disorder? Y / N

Stroke Diabetes Gout Arthritis

Thyroid Anxiety Depression Bipolar

Past surgical history (check all that apply): Gastric banding Gastric bypass Hysterectomy

Medications (list all current medications, including over-the-counter medications, supplements, and herbs):

Allergies: (Medications) (Food)

Smoking:Never Never Prior treatment for alcoholism? Y / N Drugs:NeverCurrent Never

Past smoker (quit packs/day) Regularly (drinks per day)

Obesity (check all that apply):

Diabetes (check all that apply):

Father Son MotherFather DaughterSon High blood pressure

Thyroid problems Cancer (type/s):

Periods are: Regular / Irregular Heavy / Normal / Light

(Check all that apply) Recent weight loss more than 10 pounds Recent weight gain more than 10 pounds

Snoring Difficulty breathing when flat Swelling ankles/extremitiesAbdominal pain Constipation Dysphagia/difficulty swallowingIndigestion Increased appetite Gas and bloating Nighttime urination Back pain (lower)Joint pain

Decreased appetite Urinary frequency/urgency

Back pain (upper) Muscle aches/pain

Depression Inability to concentrate

Cold intolerance Heat intolerance

Abnormal/excessive menstruation