Weight assessment questionnaire

SECTION ONE Personal Information
Name
Email address
Phone
Age (years)
Your height (centimentres or inches (5' = 60 inches))
Your weight (kilograms or pounds (14lb = 1 stone)
Are your currently taking any prescriptive medication (YES or N0)
If yes please list here:

Are you taking any over the counter medications YES or NO
If yes, please list them here;

Are you taking any natural remedies YES or NO
If yes, please list them here;

How many cups of caffeinated beverages (coffee, tea, coke...) do you drink a day ?	0 2-3 4 or more
How many standard alcoholic drinks do you drink a week?	0 1-3 4-6 7-10 11 or more
Do your smoke? YES OR NO
If yes, how many cigarettes a week	Less than 20 20 - 40 40 - 60 60 or more
Do you feel you are overweight?	Yes No Underweight
If yes, how many kilos would you like to lose?	1-5 6 - 12 13-19 20 - 30 30 +
Have any of your immmediate family suffered from weight gain? YES or NO

Generally do you feel? (tick applicable boxes)
	challenged unmotivated depressed fearful of food you have low libido alienated anxious out of control overwhelmed unattractive fearful angry
Do you feel you need to? (tick applicable)	forgive and forget move forward make changes in your life
Did you gain weight after? (please tick applicable)
	pregnancy during menopause retirement divorce giving up sport/injury giving up smoking/drugs major life trauma other
What ways in the past, if any, have you used to try and lose weight?

Were any of these attempts successful? YES Or NO?


Are you pregnant? YES or NO
Are you breastfeeding? YES or NO
If you have children, how old is your youngest child?
What is your motivation for losing weight?

SECTION TWO - Physical and mental health
Do you experience? (tick where applicable)
	sugar cravings feeling irritable or oversensitive exhaustion or fatigue digestive issues rapid mood swings poor concentration feel like crying for no apparent reason need stimulants such as coffee or sugar to get through the day difficulty sleeping recurrent infections dizziness or fainting excessive perspiration rapid heart beat anxiety attacks
Do you suffer from Type 1 Diabetes? YES or NO
Do you suffer from Type 2 Diabetes? YES or NO
If you have had recent surgery please indicate the type of surgery
Have you ever suffered from cancer? If so what type
If so please indicate cancer treatment received
Do you suffer from hypertension (high blood pressure)? YES or NO or don't know
Do you suffer from hypotension (low blood pressure)? YES or NO or don't know
Do you have high cholesterol? Yes, NO or don't know
Do you suffer from ulcers eg gastric or duodenal? YES or NO or don't know
Do you suffer from Hashimotos disease? YES or NO or don't know
Do you suffer from Grave's disease? YES or NO or don't know
Do you suffer from Hypothyroidism (underactive thyroid)? YES or NO or don't know
Do you suffer from Hyperthyroidism (overactive thyroid)? YES or NO or don't know
Are you being affected by? (tick where applicable)
	continuous fatigue muscle cramp & trembling intolerance to cold lumpy breasts cold hands and feet unexplained weight gain dry skin times of depression
	fibromyalgia glandular fever auto immune disturbances PCOS (polycystic ovaries) ovarian cysts fibroids
If you have any other illness or medical condition please list below
SECTION THREE - weight history
were you overweight as a child? YES or NO
At what age (years) did you begin struggling with your weight?
where are your weight problem areas?	arms waist thighs breasts hips calves neck bottom all over
Do you? (tick where applicable)
	become hungry mid afternoon become tired mid afternoon snack on sweets and sugary foods eat high fat foods eat when you are not hungry experience excessive hunger snack or eat after 8 pm eat alot of bread, rice, pasta eat alot of processed foods skip meals eat big portions
When you are ready please submit this questionnaire and an Elementa health coach will contact you to advise you of potential next steps towards permanent weight loss and health