Nutrition History and Questionnaire

Florida Surgical Weight Loss Center

Name: ________________________________________________
DOB: ________________________________________________
Occupation: ________________________________________________
Highest Education Level Completed:
Grade School High School College Graduate Degree
Surgery Type:
Gastric Sleeve Roux-en-Y Gastric Bypass Duodenal Switch
Surgeon: ________________________________________________________________________

Medical History (please check all that apply)

Arthritis High Cholesterol Orthopedic surgery
Cancer High Triglyceride Orthopedic surgery
Type:_____________ Level Shortness of Breath
Depression Hyperthyroidism upon Exertion
Eating Disorder Hypothyroidism Sleep Apnea
Gastric Reflux Kidney Disease Type 1 Diabetes
Heart Disease Lupus Type 2 Diabetes
High Blood Pressure Multiple Sclerosis

Please list any food allergies or intolerances: ________________________________________________

Why do you want to lose weight?

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What are some of the things that have kept you from accomplishing weight loss?
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Who would you consider your “support persons” during this process?
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What is your goal weight? ________________________________________________
What is the most you have weighed (in your adult life) and at what age? __________________________
What is the lowest you have weighed (in your adult life) and at what age? _________________________
Past Attempts at Weight Loss (please be as specific as possible):
Weight Watchers Zone Diet
Duration: ________________________ Duration: ________________________
Amount of Weight Lost: _________lbs Amount of Weight Lost: _________lbs
Reason for Stopping Program: Reason for Stopping Program:
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Jenny Craig HCG Diet
Duration: ________________________ Duration: ________________________
Amount of Weight Lost: _________lbs Amount of Weight Lost: _________lbs
Reason for Stopping Program: Reason for Stopping Program:
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Nutrisystem South Beach Diet
Duration: ________________________ Duration: ________________________
Amount of Weight Lost: _________lbs Amount of Weight Lost: _________lbs
Reason for Stopping Program: Reason for Stopping Program:
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Optifast Overeaters Anonymous
Duration: ________________________ Duration: ________________________
Amount of Weight Lost: _________lbs Amount of Weight Lost: _________lbs
Reason for Stopping Program: Reason for Stopping Program:
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SlimFast Paleo Diet
Duration: ________________________ Duration: ________________________
Amount of Weight Lost: _________lbs Amount of Weight Lost: _________lbs
Reason for Stopping Program: Reason for Stopping Program:
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Atkins Hypnosis
Duration: ________________________ Duration: ________________________
Amount of Weight Lost: _________lbs Amount of Weight Lost: _________lbs
Reason for Stopping Program: Reason for Stopping Program:
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MediWeight Loss Physician-supervised Diet
Duration: ________________________ Duration: ________________________
Amount of Weight Lost: _________lbs Amount of Weight Lost: _________lbs
Reason for Stopping Program: Reason for Stopping Program:
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 Dietitian-prescribed Diet Any other “fad” diet
Duration: ________________________ Elaborate: ________________________
Amount of Weight Lost: _________lbs Duration: ________________________
Reason for Stopping Program: Amount of Weight Lost: _________lbs
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Cleanse/Detox Diet ________________________________
Duration: ________________________ Self Diet
Amount of Weight Lost: _________lbs Elaborate: ________________________
Reason for Stopping Program: Duration: ________________________
________________________________ Amount of Weight Lost: _________lbs
Reason for Stopping Program
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Have you ever taken prescription or over-the-counter medications for weight loss, suppression of
appetite or other dieting reason? If yes, please indicate below:
Type: __________ Type: __________
Duration: ________________________ Duration: ________________________
Amount of Weight Lost: _________lbs Amount of Weight Lost: _________lbs
Reason for Stopping________________ Reason for Stopping________________

Have you ever attended a weight-loss retreat, rehab, or spa? If so, please indicate below:
Type: __________ Type: __________
Duration: ________________________ Duration: ________________________
Amount of Weight Lost: _________lbs Amount of Weight Lost: _________lbs
Reason for Stopping________________ Reason for Stopping_______________

Please provide details of any previous surgeries or other weight-loss measures you have undergone that
were not previously mentioned:
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Please list all vitamins, herbs or other dietary supplements you take and how often:
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How often do you typically consume “fast food?" __________times per day week month
How often do you eat out at dine-in restaurant? __________times per day week month
Please list the names/types of the restaurants at which you tend to eat (ex: McDonald’s, BBQ, Chinese
takeout, etc.):
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How often do you eat food from a vending machine? times per day week month
How often do you eat in a cafeteria or buffet? times per day week month
How often do you prepare and consume meals at home? times per day week month
Hay often do you consume frozen meals? times per day week month
How often do you consume “sweets”? times per day week month
Please list the types of sweets you consume: (ex: cookies, ice cream, chocolate, donuts, etc):
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Any particular diet guidelines follow at home? Yes No
If yes, please describe: ____________________________________________________________
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How often do you consume…

Water? Never 1-3 3-5 >5 times per day week month
Soda? Never 1-2 3-5 >5 times per day week month
Diet Soda? Never 1-2 3-5 >5 times per day week month
100% Fruit Juice? Never 1-2 3-5 >5 times per day week month
Tea? Never 1-2 3-5 >5 times per day week month
Sweet Tea? Never 1-2 3-5 >5 times per day week month
Fruit-flavored drinks? Never 1-3 3-5 >5 times per day week month
Sports drinks? Never 1-3 3-5 >5 times per day week month
Coffee? Never 1-3 3-5 >5 times per day week month
What do you usually add to your coffee? _____________________________________________

Please check the condiments that you usually consume at least 3-5 times per week or more:
Butter Cream-based Salad Whipped Cream
Mayonnaise Dressing Syrup
Olive Oil Canola Oil Honey
Margarine Mustard Agave Nectar
Oil-based Salad BBQ Sauce Other; please
Dressing Tabasco Sauce specify:___________
How often do you consume vegetables? times per day week month
What are your favorite types of vegetables to consume?
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How often do you consume fruits? times per day week month
What are your favorite types of fruits to consume? ___________________________________________
How often do you consume meats? times per day week month
What are your favorite types of meats to consume? __________________________________________

If you are a vegetarian or vegan, what are your sources of protein in your diet?
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How often do you consume alcohol? __________times per day week month
Do you smoke? _______ If yes: ________pack(s) per day

Please indicate which dieting barriers apply to you most:

Portion sizes Stress eating Work schedule
Not feeling full Lack of knowledge Other; please
Snacking regarding “healthy specify:___________
Late night hunger foods” or diets _________________
Binge eating Financial barriers
Emotional eating Temptations within
household

Do you exercise? Yes No

If yes, please list the types of physical activity below:
Physical Activity How Many Times Per Week How Many Minutes

If no, please describe any physical disabilities or other reasons that would prevent you from
participating in a fitness routine:
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24-Hour Recall
Instructions: Please list yesterday’s intake (or a typical day). Be as specific as possible. List the time you
ate, the type of food, and the quantity. Don’t forget beverages! If the food was from a restaurant,
include the name of the restaurant.

Example:
7am - 2 scrambled eggs, small handful of shredded cheddar cheese, 2 pieces of white toast, 2 Tbs butter,
1 medium apple, 8oz fat free milk
10:30am - 1/2 c low fat cottage cheese, 2 Tbs raspberry jam, 2 lightly salted rice cakes,
2 Tbs crunchy peanut butter, 1 bottle of water
1pm - Panera chicken Caesar salad and cup of tomato soup, 16oz green tea, 1 personal size bag of chips
6pm - grilled chicken breast (size of the palm of my hand), 1 medium baked potato, 2 Tbs sour cream,
small handful of shredded cheese, sprinkle of bacon bits, 2 glasses of white wine
8pm - 3 scoops of chocolate ice cream and 2 Publix chocolate chip cookie
2 additional bottles of water throughout the day

Day: ______________________
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