Community Specialist Weight Management Service Tier 3
History Sheet

Name:NHS Number:

Telephone Number:Consultant:

Weight Management Programme: Weight and Wellbeing Programme Yes No

If No other: ……………………………………………Date completed service: .…………………

Date………………....…….………………
Height ……….…………..………………
Weight ….……………kg ….…..…….St Ideal Body Weight 25xH2...……….Kg
BMI ………………….……………kg/m2
Waist size…………………..cm………………ins Target Weightloss……………………..

Co-morbidity (medical problems)

Are you diabetic? / Yes / No
If Yes, how long have you been diabetic / ...... Years
If Yes, please tick how this is managed /
Insulin How much?......

Tablets Which ones?......
Diet alone
Do you have high blood pressure? / Yes / No
If Yes, please state what medication you are on:
......
......

Co-morbidity (medical problems) continued

Have you had a heart attack? / Yes / No
If Yes, please state when?
Do you have any other heart problems? / Yes / No
If Yes, please state: ......
Do you have high cholesterol? / Yes / No
If Yes, please state what medication you are on:
......
......
Do you have Arthritis/Joint pains? / Yes / No
If Yes, please tick the following: Hips / Left / Right
Knees / Left / Right
Spine / Yes / No
Do you suffer with asthma? / Yes / No
If Yes, please state what medication you are on:
......
Do you have regular indigestion? / Yes / No
If Yes, what medication you take ......
Do you have sleep apnoea? / Yes / No

Health and Lifestyle

Do you smoke? / Yes / No
If Yes, how many cigarettes do you smoke? /
cigarettes a day
Do you drink alcohol? / Yes / No
If Yes, how many units you drink? /
units a week

Weight Loss

Have you attended any weight loss programs in the community? / Yes / No
Please describe your previous weight loss/es and also state your maximum weight loss. / ......
......
......
......
Maximum Weight loss......
Have you attended Slimming Clubs? / Yes / No
Have you attended Gym or Exercise classes? / Yes / No
Have you taken Orilstat (Xenical)? / Yes / No
Have you taken Sibutramine (Reductil)? / Yes / No
Have you been to a Dietician? / Yes / No
Have you been seen by a Hospital Dietician? / Yes / No
Have you attended a hospital weight reduction clinic? / Yes / No
Do you want to be considered for Bariatric Surgery? / Yes / No / Undecided

Physical Activity

Do you currently exercise? / Yes / No
If Yes, how often you do exercise? / ...... days each week
Are you able to walk for 5 minutes without stopping? / Yes / No
If Yes, please tick how long can you walk for without stopping. /
  • 5- 10 minutes
  • 10 – 20 minutes
  • 21 – 30 minutes
  • 31 – 40 minutes
  • 41 – 50 minutes
  • 51 – 60 minutes
  • 60 + minutes

If No, please tick how long can you walk for without stopping. /
  • 0 – 1 minute
  • 1 – 2 minutes
  • 2 – 3 minutes
  • 3 – 4 minutes
  • 4 – 5 minutes

Are you able to perform your normal activities of daily living, i.e. put your clothes on, climb stairs, go shopping, without getting out of breath or having a rest? / Yes / No

Dietary History

Do you enjoy eating chocolates? / Yes / No
If Yes, please circle how many bars/packets you have each week
Normal size or Family Size / 1-5 5-10 10-20 20-30 30-40 40+
Do you enjoy eating biscuits? / Yes / No
If Yes, please state how many biscuits you have each day /
each day
Do you enjoy eating sweets? / Yes / No
If Yes, please state how many medium sized packets you have each day /
each day
Do you enjoy drinking Fizzy pop? / Yes / No
If Yes, please state how many litres you have each day /
litres each day
Do you enjoy eating savoury snacks (pies, sausage rolls)? / Yes / No
If Yes, please state how many you eat each day /
each day
Do you tend to eat large portions? / Yes / No
Do you tend to graze on foods? / Yes / No
Do you enjoy eating take aways? / Yes / No

Which food or food group, do you think has contributed to your weight gain?

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