My Best Weight Intake Questionnaire

Intake questionnaire

This 5-minute questionnaire has no right or wrong answers—just what’s true for you. Your responses help our care team understand your needs and guide treatment decisions.

Tip: You can move back and forth between pages. Your answers stay in place.

About You

Let us start with a few general questions about who you are.

Name

Date of birth

E-mail

Phone number

Address

GP Address and Telephone

Sex

Male Female Another identity Prefer not to say

Marital status

Ethnicity

Occupation

Thanks. Now let us dive deeper into your medical history. This can save time during your clinic visit.

Medical History

The disease of obesity can be connected to many different organs, including your heart, liver, and kidneys. Let us explore where your health is today.

Heart and Circulation

Have you ever been diagnosed with, or treated for, a heart or blood vessel condition?

No Yes

Have you ever smoked or vaped?

Never Former Current

Diabetes

Too many fat cells, especially around the mid section, can increase your risk of insulin resistance and type 2 diabetes.

Have you ever been diagnosed with diabetes or prediabetes?

No Prediabetes Type 2 diabetes Gestational diabetes (during pregnancy)

Does diabetes run in your family?

Yes No Not sure

Digestive and Liver Health

Have you been diagnosed with any digestive or liver conditions?

No Yes

Do you drink alcohol?

No Yes

Kidney and Bladder Health

Have you ever had kidney or bladder problems?

No Yes

Sleep and Lung Health

Weight and sleep affect each other. Conditions like sleep apnea are common and treatable.

Have you ever been diagnosed with a sleep or breathing condition?

No Yes

During sleep, has anyone noticed:

Loud snoring Pauses in breathing Neither

Reproductive and Hormonal Health

Has your weight affected your reproductive or hormonal health?

No Yes

Are you planning pregnancy in the next year?

Yes No Not applicable

Surgery History

Have you had any surgeries in the past?

No Yes

Medications

Knowing which medications you are currently taking helps us understand your current health status.

Please list medication name, dose, frequency, and whether it is current or past. Example: Atorvastatin 20mg daily, current.

I am not currently taking any medications

Medication name

Dose

Frequency

Status

Weight History

A lot of people experience ups and downs with their weight. These questions help us understand your experience.

What do you think about your own health?

Do you think of yourself as healthy?

Yes No

How much weight do you think you need to lose to become healthier?

Have you needed medication for depression?

Yes No

Have you ever had another psychiatric diagnosis?

Yes No

What has your weight journey been like?

What has been your heaviest weight?

How much do you weigh now?

How tall are you?

What is the most weight you have ever lost?

How quickly did you regain most or some of the weight you previously lost?

Have you ever used medication for the disease of obesity?

Yes No

How would you describe your body image?

What do you see when you look in the mirror?

Do you avoid looking in mirrors?

Yes No

How has weight impacted your day to day life?

Economic impact

Has your weight ever impacted your job?

Yes No

Have you ever felt discriminated against at work due to your weight?

Yes No

Functional

If you have to climb 3 flights of stairs, where do you rest for the first time?

Do you stop because of shortness of breath?

Yes No

Do you stop because of knee or back pain?

Yes No

Anything else you want your care team to know?

Short answer

All set

We look forward to seeing you soon at My Best Weight.

In the meantime, you have access to the My Best Weight Care Companion designed to help you get started on your weight-management journey. You can ask questions at any time, explore treatment options, and begin thinking about nutrition or activity in a way that feels right for you before your appointment.

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