Yale Metabolic Health and Weight Loss Program
Patient Entry Form
NAME: ___________________
DATE OF BIRTH: ____________________
PLEASE LEAVE BLANK ANY TOPICS YOU WOULD PREFER TO DISCUSS IN
PERSON
Reason for Weight Loss Program referral:
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Patient goals and expectations
How much weight are you expecting to lose?
Over what time?
Any other expectations……………………………………………………………………………..
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How important is weight loss to you?
� Slightly
� Moderate
� Very
� High Priority
How much time a day are you prepared to apply to weight loss changes?
� 10-20 min
� 20-30 min
� 30-60 min
Are you interested in a specific type of treatment (e.g., nutrition education, medications)?
………………………………………………………………………………………………………
What is your age, height and weight:
Your Weight History
Early Childhood (up to 6 years old):
� underweight
� average weight
� overweight
� very overweight
Late Childhood (6 years to puberty)
� underweight
� average weight
� overweight
� very overweight
Ages12 through 20 years
� underweight
� overweight
� very overweight
� average weight
Approximate weight in pounds during:
20 - 30 years
35 - 50 years
50 - 65 years
Family History: Are any family members overweight?
� Mother
� Father
� Siblings
� Spouse/partner
� Children
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Triggers of weight gain: In your opinion, which factors are the most important causes of your
weight gain?
� Pregnancy
� Stopping smoking
� Family history
� Change in activity level (describe):
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� Emotional factors (describe):
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� Medicines (describe):
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� Other events or factors (describe):
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Please answer the following questions regarding your lifestyle:
My sleep hours are: ______________________
My work hours are: ______________________
My internet hours a day total are: ___________
Nutrition and Physical Activity
1. Household members:
Please list all members of your household and their relationship to you
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2. Which family member(s) is responsible for grocery shopping?
� Yourself
� Spouse/partner
�Other: …………………
3. Which family member(s) are responsible for cooking?
� Yourself
� Spouse/partner
� Other:……………………
4. Overall, when do you eat most of your food?
� At meals � In snacks
� Both
� Varies
5. Which meal is the largest?
� Breakfast
� Lunch
� Dinner
6. When are the largest snacks?
� Morning
� Afternoon � Nighttime
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How often do you usually have a meal in each of these types of restaurants?
Fast food – e.g., McDonald’s, Burger King etc.
� Never � Less than 1 time/week � 1 time/week � 2-3 times/week � 4 or more/week
Primary reason for use: � Business � Social � Convenience
Moderately-priced restaurants
� Never � Less than 1 time/week � 1 time/week � 2-3 times/week � 4 or more/week
Primary reason for use: � Business � Social � Convenience
High-priced restaurants
� Never � Less than 1 time/week � 1 time/week � 2-3 times/week � 4 or more/week
Primary reason for use: � Business � Social � Convenience
Take-out food – e.g., Pizza, subs, Chinese food, etc.
� Never � Less than 1 time/week � 1 time/week � 2-3 times/week � 4 or more/week
Primary reason for use: � Business � Social � Convenience
How often do you usually have any of these beverages?
Juice
� None
� 1-2 servings/day
� 3-5 servings/day
Soda
� None
� 1-2 servings/day
� 3-5 servings/day
Soda (diet) � None
� 1-2 servings/day
� 3-5 servings/day
Coffee / tea � None
� 1-2 servings/day
� 3-5 servings/day
Smoothies
� None
� 1-2 servings/day
� 3-5 servings/day
Milk-based drinks (latte, Frappucino, etc.)
� None
� 1-2 servings/day
� 3-5 servings/day
� 6+ servings/day
� 6+ servings/day
� 6+ servings/day
� 6+ servings/day
� 6+ servings/day
� 6+ servings/day
How often did you have a drink containing alcohol in the past YEAR?
� Never � Monthly or less � once/week � 2-4 times/week � 4 or more times/week
In the past year, on a typical day when you were drinking, how many drinks would you have?
� I don't ever drink alcohol � 1 � 2 � 3 � 4 � 5-6 � 7-9 � 10 or more
In the past year, how often did you have 5 or more drinks on one occasion?
� Never � Monthly or less � once/week � 2-4 times/week � 4 or more times/week
Cigarette use
� None
� 1/2 pack/day or less
� I quit smoking _______ years ago
� 1/2-1 pack/day
� More than 1 pack/day
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Do you have any food allergies/intolerances?
If yes, please list:
List any dietary or vitamin/mineral supplements you take:
Typical Intake: (Please list everything you eat and drink in a typical day).
First Meal
Time:
Second Meal
Time:
Third Meal
Time:
Snacks
Midmorning:
Time:
Afternoon:
Time:
Evening:
Time:
Physical activity patterns
Do you do any regular exercise, including walking to/from work/school, walking dog, etc.?
� Yes
� No
If yes, what type of exercise do you do?
How many minutes at a time do you typically do this exercise for?
How many days a week do you do this exercise?
How would you describe your activity during a typical day at work or home? (circle one)
� Sedentary (sit most of day)
� Active (on my feet most of day)
� Very active (lifting, walking, on feet all day, construction)
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Personal History
Your Family:
Spouse or Partner:
� Never married
� Divorced
� Married
� Widowed
� Cohabitating
� Separated
� Remarried (e.g. 2nd, 3rd marriage)
Children: Do you have any children? � Yes � No
If yes, please give the following information:
Age / gender
Is he or she living with you?
Years / M : F
� Yes
� No
Years / M : F
� Yes
� No
Years / M : F
� Yes
� No
Years / M : F
� Yes
� No
Years / M : F
� Yes
� No
Education:
1. What is the highest grade or year of school you completed?
� 8th grade or less
� Started but did not complete college
� Some high school, did not finish
� Graduated from two-year college
� Graduated high school or earned GED
� Graduated from four-year college
� Vocational, trade, or technical school
� Finished post-college degree (e.g., Master’s etc.)
2. If you are currently a student, do you attend classes?
� Part time
� Full time
Employment:
1. Which of the following best describes your occupational status?
Currently employed
� Full time � Part time
Please list occupation/job title:
� Disabled
If disabled, please state what year this began, and reason for disability:
___________________
� Retired
� Unemployed
� Student
� Volunteer. Describe: ______________
� Other. Describe: __________________
� Stay-at-home parent/homemaker
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Your Medical History
Medical Problems
Please list all of your known medical conditions, and when they were first diagnosed:
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Surgery
Please list any surgery you have had, and when each was done:
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Medications
Please list all medications you are currently taking, including nonprescription drugs. Include
the frequency and dose, if known:
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Allergies
Drugs/Latex:
……………………………………………………………………………………………
Other:
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Your Medical Conditions
Pulmonary
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� No
� No
� No
� No
� No
� No
� No
Smoked within the past year
Require oxygen
Had a pulmonary embolism/blood clot in lung
Chronic obstructive pulmonary disease (COPD)
Obstructive sleep apnea
Use CPAP/BiPAP
Asthma
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Gastrointestinal
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
Heartburn requiring medications
Gallstones or had your gallbladder removed
Pancreatitis
Fatty liver disease
Previous weight loss surgery
Musculoskeletal
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
Back pain
Disc disease in the back
Rheumatoid arthritis
Osteoarthritis
Musculoskeletal disease
Limitation of activity by pain
Daily pain medication required
Surgery for joints planned
Mobility devices used (cane, walker, etc)
Renal/Kidney
� Yes � No
� Yes � No
� Yes � No
� Yes � No
Kidney disease
Kidney Failure requiring dialysis
Urinary or Stress Incontinence
Kidney Stones
Cardiac/Vascular
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
Heart attack
Cardiac catheterization (stent in the heart)
Cardiac surgery
Elevated cholesterol
High blood pressure
Blood clot in the leg (DVT)
Venous stasis
Peripheral vascular disease
Cellulitis
Family History of Clots
Endocrine
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
� Yes � No
Diabetes Mellitus, Oral medications, or Insulin (Circle One)
Insulin Resistance
Diabetic eye disease
Chronic Steroids/Immunosuppression
Gout
Thyroid disease
Polycystic ovary disease
Reproductive disorder
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Neurologic
� Yes � No
� Yes � No
� Yes � No
� Yes � No
Stroke
Migraines
Headache
Numbness
Other
� Yes � No
� Yes � No
� Yes � No
Blood thinner Reason:________
Cancer. Type:_____________
Rheumatologic Disorders
Your Family Medical Conditions
Please specify who in your family has the following diseases: consider grandparents, parents,
aunts, uncles, siblings, children, nieces, nephews, grandchildren.
Diabetes
� Yes � No
If yes, who? …………………………...
Heart Disease
� Yes � No
If yes, who? …………………………...
Stroke
� Yes � No
If yes, who? …………………………...
Obesity
� Yes � No
If yes, who? …………………………...
High Blood pressure
� Yes � No
If yes, who? …………………………...
Thyroid problems
� Yes � No
If yes, who? …………………………...
High cholesterol
� Yes � No
If yes, who? …………………………...
Substance abuse disorders
� Yes � No
If yes, who? …………………………...
Eating disorder
� Yes � No
If yes, who? …………………………...
Other psychological disorder � Yes � No
What type of disorder? ..……………………
Cancers � Yes � No What type of cancer? …………………………………………
Other diseases that run in your family? Please list which relatives have the problem
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Your Mental Health History:
Have you ever had symptoms of or been diagnosed with any of the following illnesses?
Anorexia nervosa
� Yes
� No
� Unsure
Bulimia nervosa
� Yes
� No
� Unsure
Binge-eating disorder
� Yes
� No
� Unsure
Other type of eating disorder
� Yes
� No
� Unsure
If so, what type? ____________________
Learning disability:
� Yes
� No
� Unsure
If so, what type? _____________________
Personality disorder:
� Yes
� No
� Unsure
If so, what type? _____________________
Depression:
� Yes
� No
� Unsure
Bipolar disorder (manic-depression):
� Yes
� No
� Unsure
Anxiety disorder:
� Yes
� No
� Unsure
If so, what type?______________________
Panic attacks:
� Yes
� No
� Unsure
Phobia(s):
� Yes
� No
� Unsure
Obsessive-compulsive disorder:
� Yes
� No
� Unsure
Posttraumatic stress disorder:
� Yes
� No
� Unsure
Schizophrenia or schizoaffective disorder:
� Yes
� No
� Unsure
Alcohol dependence or abuse
� Yes
� No
� Unsure
Drug dependence or abuse
� Yes
� No
� Unsure
Other type of emotional problem or mental illness: � Yes
� No
� Unsure
If so, what type(s)? ___________________
Have you ever intentionally injured yourself?
� Yes
� No
If so, when and how? __________________
Have you ever tried to kill yourself?
� Yes
� No
If so, when and how? __________________
Have you ever intentionally injured someone else? � Yes
� No
If so, when and how? __________________
Mental Health Treatment:
1. Are you currently seeing a therapist?
� Yes
If YES, please list this provider’s name and telephone number
� No
Name: …………………………………………………Telephone: …………………………
2. Have you ever received mental health therapy or counseling in the PAST? � Yes � No
If YES, please list the approximate dates of treatment, provider’s name, and reason for treatment
Dates of Treatment Clinician’s name Reason(s) for treatment
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3. Are you currently taking any psychiatric medications?
� Yes
� No
If YES, please be sure to list these medications on the medications list
If YES, please list the name and telephone number of the provider who prescribes these
medications
Name: ………………………………………………Telephone: …………………………..
Have you ever received medication for emotional problems or mental illness in the PAST?
� Yes
� No
If yes, please list the names of all of the mental health medications you have taken in the past:
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4. Have you ever been hospitalized for psychiatric reasons? � Yes
� No
If YES, please provide more information about each hospitalization, to the best of your
recollection:
Dates of Treatment Institution Reasons for hospitalization
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Have you ever received treatment for drug or alcohol problems (e.g., detox, rehab, outpatient
therapy, methadone treatment)?
� Yes
� No
If YES, list approximate date(s) and substance for which you received treatment
………………………………………………………………………………………………
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Prior Weight Loss Efforts
I started dieting at age: ________
Have you lost weight and regained weight many times?
After losing weight do you gain even more back?
� Yes
� Yes
� No
� No
Below is a list of diet programs. Please indicate which of these methods you have tried, if any:
DIET OR PROGRAM
Commercial Programs:
What age were you when
you first tried this diet?
Number of
times on this
diet?
How much
weight did you
lose?
What age were you when
you first tried this diet?
Number of
times on this
diet?
How much
weight did you
lose?
What age were you when
you first tried this diet?
Number of
times on this
diet?
How much
weight did you
lose?
What age were you when
you first tried this diet?
Number of
times on this
diet?
How much
weight did you
lose?
TOPS
Weight Watchers
Jenny Craig
NutriSystem
Diet Center
Other (please list)
Medically Supervised
Liquid Diets:
Optifast / HMR / Other:
Medication(s):
Phen/fen; Redux
Meridia
Orlistat
Qysma
Belviq
Other (please give name
of drug)
Behavior Modification
programs:
run at a hospital or with a
dietitian or behaviorist
Page 11 of 12
Other (please be
specific):
What age were you when
you first tried this diet?
Number of
times on this
diet?
How much
weight did you
lose?
Overeaters Anonymous,
self-directed
diets, diet books, etc:
Thank you for taking the time to answer these important questions. This information will
enable the clinicians to provide a complete assessment and make well informed treatment
recommendation with the highest chance of satisfactory outcome.
Your answers will be held in strictest confidence.
**PLEASE HAND THIS FORM TO THE RECEIPTIONIST ON YOUR FIRST VISIT**
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