Patient Weight Assessment Report Template
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1Patient Weight Assessment
General
Nutrition
Name:
How many daily servings of
None
1 – 2
3 – 4
vegetables do you eat?
5 – 6
More
DOB:
Sex:
Height:
Weight:
How many daily servings of
None
1 – 2
3 – 4
Race:
fruit do you eat?
5 – 6
More
How many daily servings of
None
1 – 2
3 – 4
Medical History
grains do you eat?
5 – 6
More
Date of last check-up:
Allergies:
How many daily servings of
None
1 – 2
3 – 4
meat do you eat?
5 – 6
More
Previous
Medications:
How many daily servings of
None
1 – 2
3 – 4
sugar/carbs do you eat?
5 – 6
More
Injuries:
Surgeries:
How often do you
Never
Rarely
1 – 2 times
Blood Pressure:
snack?
per day
Between every meal
Cholesterol:
How often do you
Never
Occasionally
1 cup
drink coffee/tea?
per day
2 – 3 cups
4+ cups
History of…
Never
Occasionally
Cancer:
Me
Relation:
How often do you eat out?
Weekly
Daily
Always
Diabetes:
Me
Relation:
Stroke:
Me
Relation:
How many meals do you eat per day?
Heart Disease:
Me
Relation:
Do you eat at roughly the same times each day?
Heart Attack:
Me
Relation:
Do you ever skip meals?
Depression:
Me
Relation:
How many calories do you eat per meal?
Bipolar Disorder:
Me
Relation:
How many calories do you eat per day?
Headaches:
Me
Relation:
Do you shop with a grocery list?
Constipation:
Me
Relation:
Do you plan meals in advance?
Sleep Disorders:
Me
Relation:
Do you use sugar or butter substitutes?
Obesity:
Me
Relation:
Do you drink diet soda?
When do you feel hungriest?
Overall Health
Do you wake up hungry at night?
Great
Good
Fair
Do you snack at night?
Rate your overall health
Poor
Bad
Do you eat when you’re stressed or sad?
Are you currently stressed or sad?
How often do you feel
Never
Occasionally
Foods you crave:
depressed?
Often
All the time
Foods you dislike:
How often do you
Never
Sporadically
exercise?
Regularly
Daily
Exercise
How many days per week do you work on cardio?
How often do you
Never
Occasionally
Often
smoke?
Daily
Used to
Length of time spent on cardio each session:
How many cigarettes do you have per day?
How many days per week do you work on strength?
Length of time spent on strength each session:
How often do you
Never
Occasionally
Often
Injuries/conditions that interfere with exercise:
drink alcohol?
Daily
Used to
How many alcoholic drinks do you have per week?
Other
How often do you
Never
Occasionally
Often
eat fast food?
Daily
Used to
Weight at birth:
Weight 5 years ago:
How restful is your
Restful
I wake up once or twice
Weight six months ago:
sleep?
I wake up often
Fitful
Heaviest weight:
Age:
How many hours of sleep do you get per night?
Lightest weight:
Age:
Current Medication:
Target weight:
Dosage:
Eating disorders:
Starting date:
Length of time:
Dietary Restrictions:
When did weight loss/gain begin?
How often do you have headaches?
Do you live with anyone who is overweight?
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