Rex Bariatric Specialist
A. Weight/Dieting


1. List your approximate weight in pounds at the following ages?
10 y/o ____ lbs, 20 y _____ lbs, 30 y _____lbs, 40 y ____ lbs, 50 y ____ lbs, 60 _____ lbs 2. Please list your heaviest weight, (exclude pregnancies) __________ lbs __________ age. 3. Have you tried weight loss through structured dieting or other treatment? † Yes † No 4. If yes, list all food/ liquid diets or treatments attempted. Many insurance carriers require this information; therefore, please provide an accurate and complete listing. Behavioral
Physicians Weight Loss Volumetrics Personal Name of Diet/Treatment
Lbs. Lost

5. List all medications used by you for weight loss. Listed below are the most common medications. Please provide an accurate and complete list of any medications used in the past: Acutrim, Alli, Bontril, Didrex, Phentermine, Xenical, Dexatrim, Fen/Phen, Meridia, Redux. Medication
Start year
Length (Mos.)
Lbs. Lost
& Dose
Rex Bariatric Specialists, 2800 Blue Ridge Road, Suite 300, Raleigh, NC 27607 P: 919-784-7874 F: 919-784-2801 NUTRITIONAL PRE-SCREENING ASSESSMENT
B. Diet Behavior

1. Current challenges to improving my health include: 2. My hidden sources of extra calories most likely come from: Eating when bored/upset/stressed (not hungry) 3. How do you feel about making behavioral changes? a. Ready to start making changes now b. Ready to think about making changes c. Not ready to make any changes to my current lifestyle 4. How many days a week do you eat breakfast? a. Seldom b. 1 time per day c. 2 time per day 6. What is your usual pattern for the evening meal? 7. Which sources of protein do you eat most often? b. Fish and Chicken c. Eggs and Dairy d. Tofu, beans, and lentils a. I don’t know b. Rarely c. Sometimes d. Often a. No, I do not. b. With cheese, butter, or dressing c. Canned d. Fresh or frozen Rex Bariatric Specialist 2800 Blue Ridge Road, Suite 300 Raleigh, NC 27607 C: 919-784-7874 F: 919-784-2801 NUTRITIONAL PRE-SCREENING ASSESSMENT
10. Which types of carbohydrates do you choose most often: 11. How often do you eat low-fat dairy products? a. Seldom b. 1-2 times per week c. 1 time per day d. 2 times per day 12. Which types of drinks do you choose most often? a. Water b. Flavored water and diet soda c. Fruit a. 1-2 times per week b. 1 time per day c. 2 or more time per day d. None 14. Does your work or daily activity primarily include the following: a. Sitting b. Standing c. Walking or moderate lifting d. Heavy manual labor 15. How often do you exercise for 20 minutes or more each week? a. Seldom b. 1-2 times per week c. 3-4 times per week d. Daily 16. How many hours of sleep do you typically get a night? Rex Bariatric Specialist 2800 Blue Ridge Road, Suite 300 Raleigh, NC 27607 C: 919-784-7874 F: 919-784-2801


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