Weight management questionnaire

Full name

Sex

Occupation optional

Emergency contact — name

Emergency contact — phone

What is your highest weight as an adult? And your lowest?

How many times have you intentionally lost more than 5 kg? What methods did you use?

What weight-loss approaches have worked for you in the past? Which did not?

Has your weight changed unintentionally in the past 6 months (gain or loss)? How much?

What are your reasons for seeking weight management now?

What is your goal weight, and what timeline do you have in mind?

Please mark each condition and add the year diagnosed where you can.

Do you currently experience any of the following?

Tick anything that applies.

Medication or supplement

Are you taking any weight-loss medications or supplements (prescription or over-the-counter)?

Which ones and how long

Do you have any known drug allergies?

Please list

Are you on blood thinners, insulin, or sulfonylureas?

Which and dose

Have you had bariatric (weight-loss) surgery?

Type and date

Any surgeries planned in the near future? optional

Family history

How many meals and snacks do you eat per day?

How often do you eat out or order takeaway per week?

How many sugar-sweetened drinks (soda, juice, sweetened coffee or tea) per day?

Do you eat breakfast?

Do you eat late at night?

Any food allergies, intolerances, or dietary restrictions (religious, vegetarian, etc.)? optional

Do you eat in response to stress, boredom, or emotions?

How many days per week do you exercise? What type and duration?

How many hours per day do you spend sitting?

Any physical limitations preventing exercise? optional

Do you snore, gasp, or stop breathing during sleep?

Do you feel rested on waking?

Alcohol

Alcohol — units per week optional

Tobacco

Tobacco — amount optional

How many times per day do you eat? (include meals and snacks)

Do you eat at consistent times each day?

Which meals do you typically eat?

Tick all that apply, and add the usual time for each.

Which is usually your largest meal of the day?

Do you skip meals?

If you skip meals — which ones, and why? optional

How long do you usually go between meals?

Do you eat at your desk, in front of a screen, or while driving?

How often do you eat out or order takeaway per week?

How often do you eat pre-prepared, frozen, or ready meals per week?

Who does the cooking in your household? optional

What you ate and drank

Frequency

Frequency

How many servings of vegetables do you eat per day?

How many servings of fruit do you eat per day?

Frequency

Frequency — note the type in the last column

Frequency — note the type in the last column

Frequency

How much water do you drink per day?

How would you describe your portion sizes compared with others?

Do you usually go back for second helpings?

Do you finish everything on your plate even when full?

How quickly do you eat?

Do you feel hungry between meals?

On a scale of 0–10, how hungry are you before meals?

On a scale of 0–10, how full are you after meals?

Do you eat until you are comfortably full, or until you are "stuffed"?

Do you experience cravings?

If yes — what foods do you crave, and when? optional

Do you eat when you are not physically hungry?

What triggers eating when you are not hungry?

Do you eat differently on weekends vs weekdays?

How does it differ

How often do you prepare meals at home?

How long do you spend cooking on a typical day?

How confident are you in cooking healthy meals? (0–10)

Do you shop for groceries yourself?

How often do you shop? optional

Do you plan meals in advance?

Do you use a grocery list?

What foods are always available in your home? (list 5–10)

What tempting foods are hard to resist in your home?

Do you keep snacks visible (on counters, desks)?

How many people do you cook for? optional

Budget for food per week optional

Any barriers to buying healthy food?

Do you follow a specific diet?

Food allergies (list) optional

Food intolerances (list) optional

Foods you dislike or avoid (list) optional

Foods you would never give up optional

Cultural or religious food practices optional

Do you use meal replacements (shakes, bars)?

Which and how often

Do you use protein powders or sports nutrition products?

Which

How would you describe your current activity level?

On a typical day, how many hours do you spend sitting (work, driving, TV, screens)? hours

Standing or walking lightly hours

Doing moderate or vigorous activity hours

Do you use a step counter, smartwatch, or fitness app?

Average daily steps

How many days in the past week did you do at least 30 minutes of intentional physical activity? days

Do you have a physically demanding job?

Describe

Frequency

Frequency

Frequency

Frequency

Have you ever exercised regularly in the past?

What you did, and for how long

What was the most active period of your life? What were you doing?

What made you stop or reduce your activity?

Have you ever worked with a personal trainer, physiotherapist, or exercise professional?

Have you ever followed a structured exercise programme?

Describe

What activities have you enjoyed most in the past?

What activities have you disliked or found difficult?

Have you ever been a member of a gym or fitness class?

Are you currently?

Do you prefer to exercise:

Do you prefer:

What time of day do you prefer to exercise?

What stops you from being more active?

What helps you stay active or motivated?

On a scale of 0–10, how motivated are you to become more active now?

On a scale of 0–10, how confident are you that you can stick to an exercise plan?

What is one activity you would be willing to try in the next week? optional

Musculoskeletal

Cardiovascular and respiratory

Neurological and other

Has a doctor ever told you to limit your physical activity?

Why

Do you use any assistive devices?

Do you have any wounds, ulcers, or skin conditions that limit activity?

Do you experience pain during or after activity?

Where and when

Are you currently receiving physiotherapy or rehabilitation?

Any planned surgery or procedures that may affect activity?

Have you had a medical check-up in the past 12 months?

Has your doctor cleared you for exercise?

Do you monitor your heart rate during exercise?

Do you check blood glucose before or after exercise (if diabetic)?

Do you experience hypoglycaemia with exercise?

Do you warm up before and cool down after exercise?

Have you ever been injured during exercise?

Describe

Average hours of sleep per night hours

How would you rate your sleep quality?

Do you feel recovered after sleep?

How many rest / recovery days do you take per week? days

Do you experience excessive soreness after activity?

Do you use any recovery methods?

How would you rate your daily energy levels?

How would you rate your stress levels? (0–10)

Do you smoke or use nicotine?

Does this affect your breathing during activity?

Alcohol intake per week optional

Where can you exercise?

Do you have exercise equipment at home?

List

Is your neighbourhood safe and walkable?

Do you have access to:

Do you have childcare or caregiving support to allow exercise time?

What time of day is most realistic for you to exercise? optional

How much time can you realistically commit to exercise per day? minutes

How many days per week can you realistically commit? days

What are your activity goals?

What would you like to be able to do that you cannot do now? optional

On a scale of 0–10, how important is it to you to become more active?

On a scale of 0–10, how ready are you to start this week?

What is the smallest change you could make that would feel achievable? optional

What support would help you most?