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Registration / ID#:
ID Invitation #:

Weight Management Program (WMP) & Weight Care Clinic (WCC)

Name________________________________________________ Date of Birth_____________________ Age _______________
Address_____________________________________________________________________________________________________
City _________________________________________________ State ____________________
Zip ________________
Home Phone ________________________
Work Phone _________________________ Cell Phone _______________________
Preferred number
Home
Work
Cell
Occupation __________________________________________________________________________________________________
Present Weight ________________________________________ Present Height ________________________________________
Sex:
Female
Male
Email Address _________________________________________

Welcome to the clinic! To get to know you better, please take a few minutes to complete these forms. The
information helps us develop plans to achieve your weight/health goals. Please be as complete as possible. If
you have question(s) about an item, leave it blank and ask the physician.
*Please also complete the general clinic forms (also provided by the medical staff) that record your: past
medical history, past surgical history, medication list, allergies; etc. When there are duplicate areas (e.g.:
Family Medical History), please preferentially complete the section in this set of forms. You do not have to
complete them in both sets of forms. Thank you so much!
Personal Goals: What are you hoping to accomplish working with our clinic? (check all that apply)
I do not have any goals at this time and/or I do not know my goals.
Feel better
Improve mobility Decrease my risk of
Achieve a specific weight target:
disease(s)
___________ lbs
Improve
Get off insulin
Become more active
Become eligible for a surgery
health
(specify)
Decrease
Increase diet/
Other (specify):
medications
health knowledge
Barriers: Which factor(s) are keeping you from achieving your weight/health goals? (check all that apply)
NONE of items below apply to me
Diet knowledge
Physical limitations
Lack of social support
Hunger
Cravings
Frequent travel
Social events
Time
Daily schedule (eg:
Finances
Eating habits of others Slow metabolism
erratic schedule)
(eg: family, coworkers)
Hormonal issues (eg: Medications
Other diseases (eg:
Aging
thyroid; menopause; etc)
diabetes, sleep apnea)
Other (specify):
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Copyright 2014 The Regents of the University of Michigan

Medical Condition(s): Do you have any of the following medical issues/diagnoses? (Check all that apply)
NONE of items below apply to me
High Blood Pressure

Coronary Heart
disease

Osteoarthritis

Gallstones/ gallbladder
disease

Anemia

Polycystic ovarian
syndrome (PCOS)

Peripheral
Vascular disease
(eg: stroke)
Fatty Liver
disease
Mood disorder
(circle all that
apply:
Depression

Urinary stress
incontinence

Gout

Blood
clots

Acid Reflux

Asthma

Low
sex drive

Diabetes:
Type ____ (1 or 2)
(**Please also
complete the
section, on the
NEXT PAGE**)

Cancer: Please specify

High cholesterol
Obstructive Sleep
Apnea
If you have it: are
you on a CPAP/BIPAP
machine?
Circle One: YES NO

Anxiety
Bipolar

Other (specify):

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Copyright 2014 The Regents of the University of Michigan

Diabetes History Summary:

Not applicable, I do not have diabetes.

Not applicable, I have pre/borderline-diabetes

Date of diagnosis
(complete one)
What were the
circumstances
surrounding the
diagnosis? (check one)
Do you have any
diabetes-related
complications?
(check all that apply)

I was diagnosed in/on ____________________ (eg: 1998 or July 2007 or on 05/23/2001)

I do not remember the year but was diagnosed ~ ___________ years ago
It was just picked I was having
I was diagnosed I do not know/
up on routine labs
symptoms (thirst,
during another
remember the
frequent urination;
medical event
circumstances
weight changes)
No, I have none
Eye disease
Foot ulcers
Heart disease
(retinopathy)
and/or
amputations
Peripheral
Nerve damage
Kidney disease/ Erectile
vascular disease
(neuropathy)
damage
dysfunction
Gastroparesis
Other (specify):

When was your last diabetes eye exam (ie: dilated

retinal exam)?

Which diabetes medications have you ever tried/

been on?
What medications do you currently take for
diabetes?

On ____________________ (eg: on 05/23/2001)

I do not remember the exact date but approximately
~ ___________ (eg: May 2013; 4-6 months ago, etc)
I have never had a diabetes-eye exam
Many years ago
Please list: (eg: metformin)

Please list:

__________ times per day

__________ times per week
only when I am feeling symptomatic (high/low)
I do not check my blood sugars
Have you had low
If yes, how
______ times per
No
blood sugar episodes? Yes (I feel low
frequently do you
______ (eg: week,
month)
get them?
when my sugar
drops to under ___)
What was your most recent hemoglobin A1c test result?
______%
How frequently do
you check your blood
sugars?
(complete one)

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What symptoms
do you get when
low? __________
I dont know

Copyright 2014 The Regents of the University of Michigan

Weight History
1. Weight Graph: Please place dots to chart your weight over the years (your best guess for ages that
stand out in your memory eg: I was 200 lbs at age 20, 300 lbs at age 30; 250 at age 35; etc.)
550+
lbs
525

Your highest
weight as an
Adult:

500

________

475
450

Your lowest
weight as an
Adult:

425
400

________

375
350

Age(s) at
marriage(s):
not applicable

325
300

___
nd
2 ___
st

275
250

Weight on
wedding
day(s):
not applicable

225
200
175
150

st

125

nd

___
___

100
lbs
0

5 yrs
old

10

15

20

25

30

35

40

45

50

55

60

2. Birth Details (i.e.: your birth)

Birth Weight: If known
______ lbs
______ oz
Were you delivered by?:

65

70 yrs
old

If NOT known: Do you think your birth size was?:

Below
Average
Above
Average
average
Normal
C-Section
Vaginal
Were you delivered
Full Term
Prematurely
Did your mother have any complications during her
Yes
No
pregnancy with/ delivery of you? (eg: gestational
diabetes)
Did you (the baby) have any complications during
pregnancy or due to delivery?

4|Page(revised 13JAN2014)

Yes

No

Unknown
Unknown
Unknown
Unknown
Unknown

Copyright 2014 The Regents of the University of Michigan

3. Weight events: Please check any of the following life events that you think have contributed to your
weight issues. (check all that apply)
Illness/

Pregnancy Marriage Death of

NONE apply to me
disability
Psychological
loved one(s)
Divorce
event(s)
Other (specify):
Diet History
1. Diet Habit Self-Assessment: Please check any of the following types of foods (in the past or present)
that you consume on a regular basis AND assess whether or not you think they have contributed to
your weight issues. (check all that apply; some overlap between answers is possible)
Food Type
Consumed
Fast Food
Processed
foods
High fat
foods
Sweets
Southern
cooking
nd

2
Helpings:

When consumed?

Never

Never

Never

Never

Never

Past

Past

Past

Past

Past

Present

Present

Present

Present

Present

Never

Past

Present

Contributed
to weight?
yes no

Food Type
Consumed
Junk food

When Consumed?

yes

no

Soda-Pop

yes

no

Alcohol

yes

no

yes

no

yes

no

Eating Out/
Take Out
High Carb(rice breads,
pasta)
NONE of THESE APPLY TO ME

Never

Never

Never

Never

Never

Past

Past

Past

Past

Past

Present

Present

Present

Present

Present

Contributed to
weight?
yes
no
yes

no

yes

no

yes

no

yes

no

2. Diet Patterns: Please check any of following eating behaviors that you notice yourself doing (on a
regular basis). (check all that apply)
Late night eating
Binge eating
grazing (frequent snacking)
Infrequent eating (ie: eating
Disinhibited eating (ie: lacking Other (specify):
only one meal a day)
restraint)
3. Eating Triggers: Please check any of the following items that trigger eating/ hunger/ cravings. (check/
complete all that apply)
Type(s) of Food: (eg: chips)_______ Family Issues
_______________ Work Issues
_______________ Illness
_______________ Stress
_______________ Emotions
_______________ Boredom
4. Food restrictions and/or sensitivities: Please check any/all that apply. NONE
Vegan

Vegetarian

Lactose
intolerance
Gluten
intolerance

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Kosher

Allergy (specify):

Kidney/renal diet

Halal

Warfarin restrictions

Other (specify):

Copyright 2014 The Regents of the University of Michigan

5. Current diet summary:

Number of Meals
per day (average)
Typical portion
small/ below average
size(s)
medium/ average
large/ above average

Number of snacks
per day (average)
Snacking pattern
late

grazing
no
other
I do not
night
between (throughout
pattern
snack
meals
day)

Average number of times you eat out per week (i.e. cafeteria, take-out,
delivery, restaurant, fast food)
Do you think your current diet is: Well-balanced (including fruits, vegetables and protein)
Imbalanced with too many/much ________________ and not
enough __________________
Average monthly
under $300 per
over $300 per
Not known
food budget (total of month
month
meals, snacks;
This budget covers a family of ____________ (eg: family of 4; family of 1, etc)
eating out)
Previous diet/ weight loss efforts:
1. Formal Weight programs tried: Not applicable, I have never tried a formal diet program
Program (eg: Weight
Initial Degree of Success in the Program (check applicable box)
Watchers)
More than 10 lbs lost (specify #).
5 10 lbs lost Less than 5 lbs lost
Note: does not count weight regain
(or weight gain)
__________ lbs lost

__________ lbs lost

__________ lbs lost

2. Weight loss medications tried (click all that apply): Not applicable, I have never tried meds for weight
phentermine (Adipex)
Fen-Phen

Orlistat (Alli, Xenical)

Sibutramine (Meridia)

metformin (for weight)

phentermine/
topiramate (Qsymia)

3. Have you ever had an appointment with a dietician? Yes

Lorcaserin (Belviq)
Other (specify):

No

4. Have you ever had weight loss/ bariatric surgery?

No
Yes: Roux-en-Y gastric bypass sleeve gastrectomy lap band Other (specify): ____________

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Copyright 2014 The Regents of the University of Michigan

Physical Activity History

1. Historical trend: Please use this visual analog scale to estimate the AVERAGE amount of physical
activity/ exercise performed at various stages of life. Please review the scale/ interpretation and mark
by the number that best fits your assessment.
Childhood

Teens

Young adulthood (age 18-30)

Adulthood (over age 30): not applicable

2. Current exercise regimen: Not applicable: I do not exercise, regularly

Type of exercise (eg:
Number of times
Number of minutes
Intensity of exercise (mild,
walking)
performed per week per session (average)
moderate, rigorous)

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Copyright 2014 The Regents of the University of Michigan

Family History
Family Member
Mother
Father
Sibling(s) (specify)
Grandparents (specify)
Aunts/uncles (specify)

Obesity

Diabetes

Heart Disease

Cancer

WOMEN ONLY:
Age of first menstrual period?
Menstrual status (check one)
PRE-MENOPAUSAL
POST-MENOPAUSAL

What was the

Age of menopause
Circumstances Natural
first day of your
(age of last period)?
of menopause Hysterectomy
last menstrual
Uterine
period?
ablation
IF preBirth Control Pill
menopausal,
Depo-Provera
what is your birth Natural family planning
control method?
Barrier methods (condoms, etc)
abstinence
Intrauterine device (IUD)
other (specify): ___________
Have you ever been pregnant? Yes
No
If yes:

How many times have you been pregnant?

How many children have you delivered?
___________ (eg: 3 children)
If you have children, what were the birth weights?
1st child ______ lbs _______oz (eg: 8 lbs ??? oz)
2nd child ______ lbs _______oz
3rd child ______ lbs _______oz
4th child ______ lbs _______oz

How many pregnancy losses have you had?

(eg: I gained ~30 -40 lbs)
What was the average amount of weight gained
during your pregnancy/pregnancies?
Did you ever have any
If yes, did
Yes
gestational diabetes
pre/ecclampsia
complications during
you
have:
No
Pregnancy-induced
other (specify):
pregnancy?
high blood pressure

Were there any fetal

If yes,
Yes
(baby) complications?
describe:
No

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Copyright 2014 The Regents of the University of Michigan