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Thank you for taking the time to fill in as much, or as little, of this information as you desire. This will help me form a preliminary weight loss assessment prior to our first meeting which will save time during our valued time together and gives both an idea of what to expect from each other during our time together.


This questionnaire is a basic assessment of two things which are critical to your development. How you eat today vs. how you would like to eat today. What would you like most out of our time together?


Each of these questions has been carefully curated based on my own history of binge eating, weight loss, mental health and false dietary assumptions.


This information will be kept private, will not be shared with anyone other than myself and will be deleted upon your request.

At what age did weight first become a problem for you?
Have there been any circumstances or life events that have triggered weight gain for you?
During the past 6 months my weight has:
Have you lost weight with weight loss programs or diet plans in the past? If so, select from the list the program/method. (check all that apply):
Have you ever used any prescription medications for weight loss?
Have you ever had bariatric surgery?
Are you currently interested in considering bariatric surgery?
Have you ever consulted a surgeon regarding bariatric surgery?
What do you consider some of your barriers when it comes to managing your weight? (check all that apply)
How do you feel about your current eating habits?
Are you currently following a particular eating plan?
If yes, which one?
Number of meals and snacks you eat on an average day:
Food allergies / intolerances (check all that apply):
Who does the most of the cooking and/or grocery shopping at your house?
Do you drink caloric beverages such as soda, juice, sweetened tea, or coffee with creamer or sugar?
Do you drink alcohol/consume marijuana?
If yes, what kind? (check all that apply)
How many alcoholic drinks/cannabis use per week?
Are you frequently hungry?
Do you feel full after meals?
Do you have cravings for certain types of foods before bed (sweet, savory, salty, crunchy)?
How well are your cravings controlled? □ poorly controlled □ moderately controlled □ well controlled
Triggers for eating (check all that apply:)
Barriers to eating healthy (check all that apply):

Please list your food and beverage intake for the past 24 hours.

What is your usual eating pattern?
During the past 3 months, did you have any episodes of eating unusually large amount of food within a 2-hour period?
IF NO, SKIP TO NEXT QUESTION in this section A. If yes, during the times when you ate an unusually large amount of food, did you often feel you could not stop eating or control what or how much you were eating?
On average, how many days has this occurred in the past 3 months?
Did you usually have the following experience during these occasions? (Check all that apply
Would other people objectively consider this an unusually large amount of food?
During the past 3 months… A. Have you made yourself vomit as a means to control your weight?
B. Have you taken more than twice the recommended dose of laxatives or diuretics (water pills) in order to lose or avoid gaining weight?
C. Have you exercised for more than one hour specifically in order to avoid gaining weight after binge eating?
D. Have you taken more than twice the recommended dosage of a diet pill in order to lose or avoid gaining weight?
E. Have you fasted (not eating anything at all for at least 24 hours) in order to avoid gaining weight after binge eating?
Current or past history of an eating disorder?
To what extent do you enjoy physical activity?
How many days a week do you engage in moderate to vigorous physical activity, such as a brisk walk or an exercise class?
How many minutes does each bout of exercise typically last?
Type of activities you participate in regularly (check all that apply)
List equipment / spaces available to you for activity
SLEEP 1. How many hours of sleep do you average per night?
2. Do you work a night shift or shift work?
4. Do you have trouble falling asleep or staying asleep?
5. Do you feel rested after sleeping?
6. Are you tired throughout the day?
7. Do you snore?
8. Has anyone observed that you stop breathing during sleep?
9. Do you often wake up with headaches in the morning?
10. Do you take naps during the day?
11. Have you ever been evaluated for sleep apnea or other sleep related disorders?
If yes, were you diagnosed with sleep apnea?
If yes, do you use a CPAP, BiPap or other device?
4. Highest level of education completed?
5. Do you have good social support for healthy lifestyle changes?
1. Is stress a major problem for you?
2. Do you feel like you have healthy coping mechanisms for stress?
3. Do you consider yourself an “emotional eater”?
4. Do you ever feel depressed?
5. Have you ever been diagnosed with a mental health condition?
If yes, which mental health condition?


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