Lifestyle History
Diet History
Meal Time
Medical & Family History
| Condition | Patient | Mother | Father | Siblings | Grandparents |
|---|---|---|---|---|---|
| Hypertension | |||||
| Type 2 Diabetes | |||||
| Pre-diabetic | |||||
| High Cholesterol | |||||
| Sleep Apnea | |||||
| Cardiovascular | |||||
| NAFLD / Fatty Liver | |||||
| Osteoarthritis | |||||
| PCOS | |||||
| Hypothyroidism | |||||
| Others: | |||||
Surgical History, Weight Journey & Medication
Obesity-related surgery?
Weight Journey
Medication History
Page 2
Signs and Symptoms
| Symptom | Yes | No | Symptom | Yes | No |
|---|---|---|---|---|---|
| Shortness of breath | Stress incontinence | ||||
| Breathlessness on lying | Mobility limitations | ||||
| Dyspnea on exertion | Daily activity limits | ||||
| Chest pain | Leg swelling | ||||
| Palpitations | Abdominal pain | ||||
| Fainting | Heartburn | ||||
| Trouble sleeping | Depression/stress | ||||
| Fatigue | Anxiety | ||||
| Frequent urination | Weight bias (IWB) | ||||
| Bleeding history | Stigmatization | ||||
| Joint pain | Regular cycles (F) |
IWB: Believing negative stereotypes about SELF. Stigmatization: Felt negative attitude/discrimination because of weight.
Psychological & Stress Evaluation
How often? (1 = Never / 5 = Always)
Eating Phenotypes
PSS-4 (Perceived Stress Scale)
(0=Never … 4=Very Often)
/ 16
(>6: Moderate stress | >9: High stress)
Red Flags (Last Month)
Sleep: Early-morning waking or fragmented sleep.
Muscular: Jaw clenching or chronic neck/shoulder tension.
GI: Acid reflux or appetite changes.
Cognitive: Decision fatigue, irritability, or brain fog.
Metabolic: Weight plateau or late-night cravings.
Your Story
Which feels most true right now?
I want to start my healthy weight-loss journey.
I lost weight but can't maintain it.
I lost weight but regained it.
I can't lose weight despite dieting/exercise.
I lost weight but can't follow the same diet.
Anti-Obesity Medications
Notes
Obesity Stage