Weight Management Survey

Name	*
Phone	*
Email	*
Age	*
Height	*
Weight	*
Counselor	*
Facility Phone	*
Counselor's Email	*
Part 1 - Check All That Apply
Nervousness		Yes No
Irritability		Yes No
Fatigue and Exhaustion		Yes No
Faintness, Dizziness, cold sweats, weak spells		Yes No
Depression		Yes No
Drowsiness, especially after meals or in mid-afternoon		Yes No
Headaches		Yes No
Digestive disturbances with no obvious cause		Yes No
Forgetfulness		Yes No
Insomnia		Yes No
Needless Worrying		Yes No
Mental Confusion		Yes No
Rapid pulse, especially after eating certain foods		Yes No
Muscle Pain		Yes No
Antisocial Behavior		Yes No
Over-emotional, crying spells		Yes No
Lack of sex drive		Yes No
Leg cramps		Yes No
Blurred Vision		Yes No
Shortness of breath, sighing and excess yawning		Yes No
Craving for starch and sugar-rich foods		Yes No
Please list any medications you are currently taking AND the condition for which you take them:
Part 2 - Calorie Sensitive Test
You had normal body weight when younger, but slowly gained weight after age 30.		Yes No
You are presently overweight but by 25 pounds of less		Yes No
You have few, if any food cravings		Yes No
You have a normal appetite. (get hungry at mealtimes).		Yes No
You have maintained the same basic eating habits all your life.
You eat 3 meals a day		Yes No
You have gained a certain amount of extra body weight but seem to have tapered off (not continued to steadily gain more and more weight).		Yes No
You have few or none of the symptoms associated with poor carbohydrate metabolism as discussed in part 1		Yes No
Part 3 - Carbohydrate Intolerant Test
You are more than 25 Pounds overweight		Yes No
Your waist is bigger than your hips (men)		Yes No
You have a tendency to be overweight all your adult life		Yes No
You have been overweight since you were younger		Yes No
You have a poor appetite and skip meals often		Yes No
You prefer not to eat in the morning		Yes No
You have food cravings that temporarily go away when starchy or sugary foods are eaten		Yes No
There are foods that you feel you could absolutely not do without		Yes No
Your waist is more than twice the size of your hips (women)		Yes No
Most or all the sympltoms associated with carbohydrate intolerance and/or excess stress on "Part 1" apply to you		Yes No
Are you, or have you in the past year, taken any of the following classes of medications?
Thiazide Diuretics		Yes No
Epinephrine containing meds		Yes No
Steroids (ie.prednisone or cortisone)		Yes No
Anti-anxiety drugs		Yes No
Anti-depression drugs		Yes No
Statin (cholesterol) meds		Yes No
Birth Control Pills		Yes No
Beta-Blockers		Yes No
Diabetes medication		Yes No
Diet Pills Containing caffeine		Yes No
Part 4 - Insulin Profile
Do you exercise?		Yes No
If yes, how often? What Type?
Do you consume Diet Soft Drinks?		Yes No
How Many?
Do you consume alcoholic Beverages?		Yes No
Do you use artificial Sweetners?		Yes No
Do you snack between meals?		Yes No
Do you consume coffee?		Yes No
Do you consume 3 meals daily?		Yes No
Do you have food cravings?		Yes No
List in order of craving intensity
Do you have now or have you ever had any of the following:
Frequent cravings for sweet of salty, crunchy snack foods		Yes No
Difficulty losing weight even if you exercise of cut back on your foods		Yes No
Difficulty with weight gain even when eating small amounts of food		Yes No
Weight gain mostly around your waist		Yes No
Skin Tags (small, painless, floppy skin growths)		Yes No
High triglyceride		Yes No
High Cholesterol		Yes No
Afternoon fatigue		Yes No
High uric acid or gout		Yes No
Native-American, Asian, African-American, Pacific Islander or Hispanic Ancestry		Yes No
Please list any dietary supplements you are currently taking:
Family history of type II diabetes or hypoglycemia		Yes No
Please list any diet programs you have followed in the past and the results you have obtained from them.
If you have failed at weight loss programs in the past, please describe why you feel you were not successful.
Additional Comments you feel may be helpful to us
Do you suffer from any of the following
Severe Carbohydrate Intolerance		Yes No
Diabetes		Yes No
Excess Stress		Yes No
PCOS		Yes No
Hypoglycemia		Yes No
Under Active Thyroid or other glandular problems		Yes No
Menopause Symptoms		Yes No
Candida or Systemic Yeast Problems		Yes No
Do you or have you taken birth control drugs		Yes No
Arthritis/Chronic Inflamation		Yes No
How would you like to be contact with your results?	*	Email Phone Both