NUTRITION CONSULTATION
INTERVIEWER: ______________________
Please legibly print the following Nutrition Information. This form is crucial in developing an
appropriate treatment plan for you. Please answer the questions as completely as possible. Thanks!
Name: Date:
Address: City & Zip:
Age: ________________Date of Birth: ____________________ Gender: Female Male
Home Phone:_________________________________Cell Phone:________________________________
Email Address: __________________________________________________________________________
Referring Doctor: ___________________________________ SS# _______________________________
Ethnicity: Hispanic African-American Caucasian Asian American
Other_______________
Height: _________ Weight: _________lbs. Highest Weight? _______lbs. When? ________ BMI:
_____
PROCEDURE: Lap Band Gastroplasty Gastric Bypass __ Open __
Laproscopic
Revision Gastric Sleeve Other:
Obesity Related Medical History: (please check all that apply)
Curren Previou Current Previou
t s s
Sleep Apnea Incontinence
Diabetes Arrhythmia’s
High Blood High Cholesterol
Pressure
Stomach Ulcer Asthma
Arthritis Cancer
Heart Attacks Kidney Disease
Stroke Blood Clots
Gallbladder Lupus
Depression Emphysema
Heart Failure Thyroid Disease
Anxiety Reflux/GERD
Shortness of Elevated
Breath Triglicierides
Hiatel Hurnia Urinary
Incontinence
Gas/ Bloating: Constipation:
Sleep Apnea: Other:
If Diabetic: When were you first Juvenile onset Yes No
diagnosed with Diabetes? (year) Gestational/ Pregnancy Yes No
Adult Onset Yes No
Confidential, 1
Did you receive any Diabetes Diet Controlled Yes No
Education? Yes No Oral Medications Yes No
Insulin Yes No
Who is your primary care physician? _______________________________________________
Medical History continued
Do you have a history Anorexia Excessive Laxative Use
of the following? Bulimia Diuretics Use for weight control
Cigarettes Former Smoker How Much? Dietitian Notes
Pipe Other Never Smoked How Long?
Smoking
Never 1-3 drinks/week Alcohol Beverage
Former 4-5 drinks/week of choice?
Alcohol
Social 1-3 drinks/month
4-5 drinks/month
amount per Regular Type of Creamer?
Coffee/ Tea day Decaf
Artificial Type:
Sweetener
Carbonated Yes How much? Type?
Drinks & Soda No
Indicate Family Medical History: (please check box)
Mother Father Brother( Sister(s) Dietitian/ Nutritionist Notes
s)
High Blood Pressure
Heart Disease
Obesity/Weight
Issues
Cancer
Stroke
Diabetes
Depression/Bipolar
Excessive Dieting
Addiction
Current Medications:
Medication(s) Indication Dietitian/ Nutritionist Notes
Weight/ Dieting History:
What are you
currently doing to
lose weight?
Describe your weight
during childhood:
Confidential, 2
Describe your weight
at high school
graduation:
Describe your weight
during your 20’s
What do you attribute your weight gain to?
How long have you
been obese?
___________yrs.
What are you
currently doing to
lose weight?
How long have you
been at your current
weight?
Do you now, or in the Yes No If yes, please describe.
past, binge on food?
Do you have a history Anorexia Excessive Laxative Use
of the following? Bulimia Diuretics Use for weight control
Do you now or in the Yes No If yes, please describe.
past have any history
of purging on food?
What dieting Phen Fen Pondamin Fastin Dexatrim Meridia
prescription drugs or Metabolife Atipex Xenical Diuretics Amphetamines
over the counter drugs Redux
have you tried? Other
Dietitian/Nutritionist Notes:
Dieting History. Please check all that apply with information.
Diet Lbs. Lost Lbs. Gained
When
□Atkins _____________
□Weight Watchers _____________
□South Beach _____________
□Jenny Craig _____________
□Nutri-System _____________
□L.A. Weight Loss _____________
□Opti-Fast _____________
□Soup Diet _____________
□Grapefruit Diet _____________
□Zone Diet _____________
□Herbalife _____________
□Liquid Diets _____________
□Slim Fast _____________
□Medically Supervised _____________
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□Other
Do you consider Yes No If yes, please describe.
yourself an emotional
eater?
Do you consider Yes No If yes, please describe.
yourself a compulsive
eater?
Your rate of eating? Slow Moderate Fast Inhale
Do others in Yes No If yes, please describe
household have
weight issues?
Do you have any food Yes No If yes, please describe.
allergies?
Who is the primary
cook in your
household?
Food Intake Please describe what and how much you ate & drink in the past 24-hours:
Breakfast ________________________________________________________________________
Snack __________________________________________________________________________
Lunch __________________________________________________________________________
Snack __________________________________________________________________________
Dinner __________________________________________________________________________
Snack(s) ________________________________________________________________________
Was this accurate of a Yes No If yes, please describe.
“typical” daily food
intake for you?
How many meals do Typically where do you eat out?
you eat out per week?
How many meals and
snacks do you eat
during a 24 hour
period?
What are your 3 Please name.
favorite restaurants?
What do you consider
a “Good Day” of
eating?
What do you consider
a “Bad Day” of eating?
What are your favorite
foods and snacks?
Do you take any If yes, please describe:
vitamins or herbal
Confidential, 4
supplements?
Do you have food If yes, please describe:
“cravings”?
Dietitian/Nutritionist Notes:
Daily Fluid Intake
Type Amount Dietitian/ Nutritionist Notes
Water
Soft Drinks/ Soda
Flavored Water
Alcoholic Beverages
Protein Shakes/ Drinks
Coffee/ Tea
Juice
Other beverages you
drink daily?
Body Image
Please circle how you currently feel about your body (size, shape, weight, etc.):
Low body image High body
image
0 1 2 3 4 5 6 7 8 9 10
What would most like to
change about your body?
What do you like best about
your body?
What messages did you
receive about your body as
a child?
What messages did you
receive about eating as a
child?
The Surgery
What is your
motivation for
having surgery now
How long have you Have you attended a seminar about the
been considering surgery?
weight loss surgery?
Describe your
dietary plan after
surgery:
What foods will you
miss the most that
you are currently
eating?
Describe the diet
that you will have to
follow prior to
surgery and for how
Confidential, 5
long.
Week 1:
What is your
understanding of Week 2:
your diet/ food
choices immediately Week 3:
following surgery?
Week 4:
What questions do
you have about what
you can and cannot
eat after surgery?
What family and Describe WHO and HOW they will support you.
friends support you
in this decision?
Explain how they will
help you.
EXERCISE
Are you currently Yes No If yes, how often?
exercising? For how long/ duration?
What type of exercise/ How often do you engage in this
physical activity do you activity?
enjoy?
If your weight were not Does your current weight prevent you
an issue, what type of from
exercise would you like doing this exercise?
to engage in?
Dietitian/Nutritionist Notes:
Confidential, 6
_________________________________________
Patient Signature
Confidential, 7
