Weight Loss Form

You can fill out the online form below or download this form, print it out and mail it to Lee Bannister.

This questionnaire is designed, to be filled in by clients before commencing first session.
Your responses to the following questions will enable your therapist to construct and effective program to help you
to lose the weight that you want. All information is private and confidential.

Name
Email
Telephone Mobile
How much (approx) do you weigh? What is your goal weight?
When in your life were you your ideal weight?
What changed in your life when you began to gain weight?
What emotions do you associate with this period in your life? i.e. guilt, comfort, punishment, contentment, etc.

On an average day, what do you eat and how much?
a) For breakfast
b) Mid-morning
c) Lunch
d) Mid-afternoon
e) Evening meal
f) Supper
g) Other
Do you snack between meals? If so, which, and what do you snack on?
Do you ever get up during the night for something to eat
If you overeat, which of the above foods would you like to cut down on, or cut out altogether?
Approximately how many drinks do you have a day?
Do you drink fizzy or sweetened drinks? If so, how many?
Do you drink alcohol? If so, how many units per day?
Any reason you want to stay as you are?
Who does the food shopping in your household?
Who prepares and cooks the food?
Do you often leave food on your plate?
Do you enjoy: (please tick where appropriate)
Sweet foods? Savoury foods? Fresh fruit?
Fresh vegetables? Starchy foods? Fatty foods?
 
What suggestions do you feel would be most effective for helping you to achieve your goal weight? (please tick)
Stop overeating? Stop snacking between meals? Stop drinking alcohol?
Stop drinking sweeet drinks? Stop eating junk food? Take more exercise?
Have more energy? Other
Are, or were, either of your parents, brothers or sisters overweight? If so, please say which
Do you remember any instances of being 'forced' to eat up when you were younger? Yes No
Do you like the feeling of being full? Yes No
Was food ever used as a reward for doing something good? Yes No
Did you ever eat to forget about something else? Yes No
Did you often feel hungry as a child? Yes No
Do you ever eat when you are not hungry? Yes No
If yes, please give an example?
Do you ever eat to please someone else? Yes No
If yes, please give an example?
Are you constantly thinking about the next meal? Yes No
Do you have any problematic relationships in your life at present? Yes No
If yes, please state with whom.
If you answered yes, how do you see this relationship improving?
How many hours sleep (approximately) do you have per night?
Do you lead an active life? Yes No
Does your job involve sitting down a lot? Yes No
Are you involved in any sport or regular exercise? Yes No
If the answer to the above question is no, can you identify a sport that you would enjoy doing? Yes No
If yes, please say what this would be?
When would a convenient time for you to do this, be?
Do you want to exercise more? Yes No
Are you currently taking any drugs or prescribed medication? Yes No
If yes, are you aware of any side effects from these that could cause weight gain Yes No
If yes, are you willing to consult with your GP to find a more suitable alternative Yes No