Pre-Assessment Questionnaire , print or save as PDF to review offline. ← Back to online form

Initial Weight & Lifestyle Assessment

Pre-assessment questionnaire , please complete before your appointment

Doctor on the MoveDr Oyinkansola Adeyemi
Weight & Lifestyle Medicine
doctoronthemove.co.uk

Patient name

Date of birth

Email address

Phone number

Appointment date

Appointment type

1. Personal details

Full name

Email address

Phone number

Date of birth

2. Measurements

Complete what you know. If you have access to scales, please provide your current weight and height as accurately as possible.

Weight (e.g. 85 kg or 13 st 5 lb)

Height (e.g. 165 cm or 5 ft 5 in)

3. Safety questions

Please answer as accurately as you can. You can choose ‘Prefer to discuss’ where offered.

Have you had bariatric or weight-loss surgery? Yes / No

Are you currently receiving treatment from another weight-management service? Yes / No

Do you currently experience binge eating, self-induced vomiting, prolonged fasting or severe food restriction? Yes / No / Prefer to discuss

Is there anything about your physical or mental health that may affect your ability to make changes to your eating or activity? Yes / No / Prefer to discuss

4. Typical food intake

Describe a typical day of eating as honestly as you can. There are no wrong answers.

Breakfast

Mid-morning (snack, coffee, nothing?)

Lunch

Afternoon (snack, tea, nothing?)

Dinner

Evening / snacks (after dinner eating or snacking)

Drinks (tea, coffee, alcohol, soft drinks throughout the day)

Weekend eating: what is different? (takeaways, eating out, different timings)

Portions, takeaways, eating out, cooking, oils and sauces

5. Activity level

Occupation / daily activity (e.g. office-based, on feet all day)

Sedentary time (e.g. 8 hours at a desk)

Exercise / structured activity (e.g. gym twice a week, yoga)

Walking / steps (e.g. 3,000 steps/day, 20 min walk)

Typical weekly activity (overall summary)

Activities enjoyed / disliked

6. Alcohol

Type and amount (e.g. wine, 2 glasses , or "None")

Days per week

Typical weekend intake

Effect on eating / snacking

7. Goals and priorities

What would you most like to change?

What do you feel is getting in the way?

Anything else you would like Dr Adeyemi to know before the visit?