4 times per week.
17. On a scale of 1 to 5 (1=least satisfied 5=very satisfied), rate the following situations in your life.
Married Life 1 2 3 4 5 N/A
Present Job 1 2 3 4 5
Overall satisfaction with self 1 2 3 4 5
Hours of TV daily Never_______ Rarely_______ 3-5 Hrs_______ 5+ Hrs_______
Substitute eating as an emotional outlet Yes No
Number of pregnancies _______
Number of children _______
Number of miscarriages or abortions _______
18. Behavior style: (answer only one)
You are always calm and easygoing.
You are usually calm and easygoing.
You are sometimes calm with frequent impatience.
You are seldom calm and persistently driving for advancement.
You are never calm and have overwhelming ambition.
You are hard-driven and can never relax.
19. Advanced directive/living will? Yes No
20. Family History:
Age Health Disease Cause of Death Overweight?
Has any blood relative ever had any of the following:
Glaucoma: Yes No Who: Asthma: Yes No Who:
Epilepsy: Yes No Who:
High Blood Pressure Yes No Who:
Kidney Disease: Yes No Who:
Diabetes: Yes No Who:
Tuberculosis: Yes No Who:
Psychiatric Disorder Yes No Who:
Heart Disease/Stroke Yes No Who:
Adopted Yes No
Nutrition Evaluation: I have been overweight since age _______
Number of years at current weight?_______
What has been your maximum lifetime weight (non-pregnant) and when? Most weight lost on a single diet?____________________________
Is your spouse, fiancée or partner overweight? Yes No
By how much is he or she overweight?______________________________
How often do you eat out?_____________________________________
What restaurants do you frequent?__________________________________________
How often do you eat “fast foods”?______________________________________
10. Who plans meals? Cooks? Shops?
11. Do you use a shopping list? Yes No
12. Food dislikes:
13. Food you crave:
Do you use a sugar substitute? Yes No
Do you use butter _______ margarine _______
Do you awaken hungry during the night? Yes No
17. What are your worst food habits?
18. Snack Habits:
What? How much? When?