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You are here: Home / Diet History

Diet History

Dietary History

Please complete this form with your diet history so that our registered dietitians can review during your consultation.

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Name*
First Last
Date of Birth*
Month
Day
Year
Height (ft)*
For example, if you are 5'2, enter a 5.
Inches*
For example, if you are 5'2, enter a 2.
Weight (lbs)*
Please enter a number from 100 to 999.
BMI

What program(s) are you considering?*
- Gastric Sleeve
- Gastric Bypass
- Gastric Band
- Gastric Balloon
- Gastric Band Removal
- Endoscopic Sleeve Gastroplasty (ESG)
- SIPS
- Adipex/phentermine
- Contrave
- Qsymia
- Saxenda
- Other

When did you first start having an issue with your weight?*
Why did you first start worrying about your weight?*
Why do you think you have a weight problem?*
What other family members are overweight?*
- Aunt(s)
- Children
- Father
- Mother
- Spouse
- Uncle(s)
- Grandparent(s)

What was your LOWEST adult body weight? (in pounds)*
Approximately what age were you?*
Approximately what year was it?*

What was your HIGHEST adult body weight? (in pounds)*
Approximately what age were you?*
Approximately what year was it?*

What was the most weight you ever lost on any program? (in pounds)*
Approximately what year was it?*
What program was it?*
What do you consider a good weight for yourself? (in pounds)*

On previous diet attempts when you regained weight, why do you feel it happened? (hunger, boredom, lack of exercise, etc.)*

What do you feel are your barriers to keeping your weight off?*
- Emotional eating
- Food cost
- Frustration with lack of results
- Lack of motivation
- Lack of knowledge about nutrition
- Physical hunger
- No support from family or friends
- Time issues
- None of the above

How many meals do you have a day?*
Do you frequently skip meals?*
Which meal(s) do you skip most frequently?*
- Breakfast
- Lunch
- Dinner
- I don't skip meals
Why do you usually skip meals?
Who plans the meals?*
Who cooks?*
Who food shops?*
How many times do you eat out per week?*

What triggers you to eat?*
- Anger
- Boredom
- Depression
- Family gatherings
- Lack of control
- Social situations
- None of the above
How often do you overeat or binge at meals or snacks?*
Do you ever feel compulsive about foods?*
Do you usually achieve a feeling of fullness when eating meals?*
By clicking the "Submit" button I give permission for this information to be transmitted via internet to JourneyLite Physicians.
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