My Best Weight Intake Questionnaire

Intake questionnaire

This 15-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.

Fields marked * are required to continue to the next page.

Name

Date of birth

If the calendar is difficult, type your date below instead.

Accepted formats: DD/MM/YYYY, 31 Aug 1972, DDMMYYYY

E-mail

Phone number

Address

GP Address and Telephone

Sex

Male Female Another identity Prefer not to say

Ethnicity (Tip: metabolic risk can vary by ethnicity.)

Occupation

Do you consent to receiving email updates from our clinic mailing list?

Yes No

Thanks. Now let us dive deeper into your medical history. This will help your care team understand more about your health.

Medical History

Fields marked * are required to continue to the next page.

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.

Diabetes

Have you ever had any of the following? (select all that apply)

Prediabetes Type 2 diabetes Gestational diabetes (during pregnancy) None of the above

Does diabetes run in your family?

Yes No Not sure

Digestive Health

Do you have regular heartburn or reflux?

Yes No

Have you had any of the following? (select all that apply)

Gallstones Cholecystectomy (gallbladder removal) Pancreatitis None of the above

Liver Health

Has there ever been a concern about fatty change in your liver?

Yes No

Do you drink alcohol?

Yes No

Kidney and Bladder Health

Have you ever had kidney or bladder problems?

Yes No

Sleep and Lung Health

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

Yes No

During sleep, has anyone noticed:

Loud snoring Pauses in breathing Neither

Surgery History

Have you had any surgeries in the past?

Yes No

Your Health

Fields marked * are required to continue to the next page.

Has the disease of obesity had any economic impact on you?

Has your weight ever impacted on your job?

Yes No

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

Yes No

What do you think about your own health?

Do you think of yourself as healthy?

Yes No

What are you worried will happen if your weight stays at the same level for the next 10 to 20 years?

Have you needed medication for depression?

Yes No

Have you ever had another psychiatric diagnosis?

Yes No

Have you had any of the following? (select all that apply)

Anxiety Eating disorder None of the above

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 much weight do you want to lose?

How has the disease of obesity impacted your day to day life?

If you are asked 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

Weight History

Fields marked * are required to continue to the next page.

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

What has your weight journey been like?

What has been your heaviest weight?

What is your current weight (if tracked)?

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

Medications

Fields marked * are required to continue to the next page.

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.

Do you have any known drug allergies?

Yes No

I am not currently taking any medications

Medication name

Dose

Frequency

Status

Anything Else

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.

Submission

Submitting your responses…

Intake questionnaire

About You

Medical History

Heart and Circulation

Diabetes

Digestive Health

Liver Health

Kidney and Bladder Health

Sleep and Lung Health

Reproductive and Hormonal Health

Surgery History

Your Health

Has the disease of obesity had any economic impact on you?

What do you think about your own health?

How would you describe your body image?

How has the disease of obesity impacted your day to day life?

Weight History

What has your weight journey been like?

Medications

Anything Else

Anything else you want your care team to know?

All set

Submission