Diet HistoryDietary HistoryPlease complete this form with your diet history so that our registered dietitians can review during your consultation.Step 1 of 1010%Name* First Last Date of Birth* Month Day YearHeight (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.BMIWhat 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 OtherWhen did you first start having an issue with your weight?*ChildhoodAdolescenceAdulthoodWhy 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 aboveHow many meals do you have a day?*01234567Do you frequently skip meals?*YesNoWhich meal(s) do you skip most frequently?* Breakfast Lunch Dinner I don't skip mealsWhy do you usually skip meals?Who plans the meals?*Who cooks?*Who food shops?*How many times do you eat out per week?*01-34-78-1011+What triggers you to eat?* Anger Boredom Depression Family gatherings Lack of control Social situations None of the aboveHow often do you overeat or binge at meals or snacks?*NeverOccasionallyFrequentlyAlmost alwaysDo you ever feel compulsive about foods?*YesNoDo you usually achieve a feeling of fullness when eating meals?*YesNoBy clicking the "Submit" button I give permission for this information to be transmitted via internet to JourneyLite Physicians.PhoneThis field is for validation purposes and should be left unchanged.Δ