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Diet and Body Composition Assessment Form

Name:
Occupation:
Phone Number:
Email:
Address :
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Age :
yrs.
Gende
r:

Height :
cm
Weight :
kg

BMI :
%
BMR :
kcal

Reason for Weight Management Programme:


__________________________________________________________________________________
__________________________________________________________________________________
Goals and Expectation:
__________________________________________________________________________________
__________________________________________________________________________________
Are you interested in a specific type of treatment (e.g; surgery,nutrition
education,supplement,medication)?
__________________________________________________________________________________
Youre Weight History
Please indicate how large you were during each of the following age ranges:
Early Childhood (up to 6 years old)
Underweight
Average Weight
Overweight
Very Overweight
Late Childhood (6 years to puberty)
Underweight
Average Weight
Overweight

Very Overweight

Adolescene (about 12 to 18 years old)


Underweight
Average Weight
Overweight

Very Overweight

Family History of Obesity


Mother has obesity
Father has obesity
One or more of my brothers and sisters have obesity
One or more of my children have obesity

Triggers of weight gain: in your opinion, which factors are the most
important causes of your weight gain?
Pregnancy
Stopping smoking
Family history of obesity
Change in activity level (describe):
______________________________________________________________________________
Emotional factors (describe) :
______________________________________________________________________________
Medicines (describe):
______________________________________________________________________________
Other events or factors (describe):
______________________________________________________________________________
Please answer the following questions regarding your lifestyle:
On average I get ______________hours of sleep per night.
My work hours are: __________________________________________
Prior Weight Loss Efforts
I start dieting at age: ____________________
Have you lost weight and regained weight many
yes
no
sometim
times?
es
After losing weight do you gain even more back?
yes
no
sometim
es
Diet History: Below is a list of different diet programs. Please indicate
which of these methods you have tried, if any:
Diet or
What age
Number of
How much
How much
Program
were you
times on this weight did
weight did
when you
diet
you lose the you lose the
first tried
first time?
second
this diet?
time?
Commercial
Programs:
Bodykey
Shaklee
Cambridge
Herbalife
Diet Centre :
Others (please
list)

Medically
Supervised
Liquid
Diets :

Medication(s
):
Fat burner
Fat blocker
Carbohydrate
Blocker
Supplement :

Nutrition and Eating Habits


1. Household members (please list all members of your household
and their relationship to you) :
1____________________________________2____________________________________
_3____________________________________4___________________________________
__5____________________________________6__________________________________
___7____________________________________8_________________________________
____9____________________________________10_______________________________
_____
2. Which family member(s) are responsible for cooking?
Yourself
Spouse/Partner
Other :
3. Overall, when do you eat most of your food?
At meals
In Snacks
Both
4. If at meals, then which meal is the largest?
Breakfast
Lunch

Varies

Dinner

5. If in snacks, then when are the largest snacks?


Morning
Afternoon
Night-time

How often do you usually have a meal in each of these types of


restaurants?
Fast food: eg; McDonalds, Kentucky Fried Chicken, etc.
Never
<1 time/week 1 time/week
2-3 time/week >4 time/week
Primary reason for use:
Business
Social
Convenience
Moderately-priced restaurants
Never
<1 time/week 1 time/week
Primary reason for use:
Business
Social
High-priced restaurants
Never
<1 time/week
Primary reason for use:

1 time/week

2-3 time/week

>4 time/week

Convenience

2-3 time/week

>4 time/week

Business

Social

Take-out food eg; Pizza,subs, etc.


Never
<1 time/week 1 time/week
Primary reason for use:
Business
Social

Convenience

2-3 time/week

How much do you spend for each meal?


Meal
< RM 5
RM 5 -10
RM 10 -15
Breakfast
Midbreakfast
Lunch
Tea
Dinner
Supper

>4 time/week

Convenience

RM 15 -20

>RM 20

How much portion of Carbohydrates, Protein, and Fibre for each meal? (List type
and average number of serving)
Meal
Carbohydrates (scoop) Protein (amount)
Fibre
(scoop)
Breakfast
Midbreakfast
Lunch
Tea
Dinner
Supper
How often do you usually have any of these beverages?
Juice
None
1-2 /day
3-5 /day
Soda (non-diet) None
1-2 /day
3-5 /day
Soda (diet)
None
1-2 /day
3-5 /day
Coffea and/or
None
1-2 /day
3-5 /day
tea
Fruit smooties
None
1-2 /day
3-5 /day
Milk-based
None
1-2 /day
3-5 /day
drinks
(latte,frappucin
o,etc.)

>6
>6
>6
>6

/day
/day
/day
/day

>6 /day
>6 /day

How often did you have a drink containing alcohol in the past year?
Never Monthly or
Once a week
2-4 times/week 4 or more times/week
less
In the past year, on a typical day when you were drinking, how many
drinks would you have?

None

5-6

7-9

>10

In the past year, how often did you have 5 or more drinks on one occasion?
Never <Monthly
Monthly
Weekly
2-4 times
Daily
weekly
Cigarette use:
None
<
packs/day

-1
packs/day

>1 packs/day

Quit____years ago

Do you have any food allergies, intolerances?


I yes, please list :
__________________________________________________________________________________
List any dietary or vitamin/ mineral supplements you take daily (with
brand name):
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Physical activity patterns
Do you do any regular exercise, including walking to/from
work/school,walking dog, etc.? (yes/no)
If yes, what type of exercise do you do?
__________________________________________________________________________________
How many minutes at a time do you typically do this exercise for?
__________________________________________________________________________________
How many days a week do you do this exercise?
__________________________________________________________________________________
How would you describe your activity during a typical day at work or
home?
Sedentary (sit most of day)
Active (on my feet most of day)
Very active (lifting, walking, on feet all day,
construction)
Personal History
The following information will help us understand the supports, stress, and
obligations in your life. If you choose, you may skip any questions or topics.
Your family :
Spouses or partner :
Never married
Married
Divorced
Widowed

Cohabitating
Separated
Remarried (2nd,3rd,4th)

Children : Do you have any children ?


If yes, please give the following information :
Age/Gender of Child/Is he or she living with you?
--------- / M/F / (yes/no)
--------- / M/F / (yes/no)
--------- / M/F / (yes/no)
--------- / M/F / (yes/no)
--------- / M/F / (yes/no)
--------- / M/F / (yes/no)
Education :
1. What is the highest grade of school you completed? (Circle the answer)
PMR/SPM/STPM/Diploma/Degree/Master/PhD
2.If you are currently a student,do you attend classes
Part time/ Full time
Employment
1. Which of the following best describe your occupational status?
Currently employed _____
Full time _____
Part time _____ :________________________
Disabled_____:____________________________
Retired _____
Unemployed _____
Student ____
Stay at home parent/homemaker ____
Volunteer ___:________________________
Other ___:_____________________________
Your mental health history
Have you ever had symptoms of or been diagnosed with any of the
following illness ?
Illness
yes N Unsu Remarks
o re
Anorexia
nervosa
Bulimia nervosa
Binge-eating
disorder
Learning
disability
Personality
Disorder
Depression
Bipolar
Panic attacks
Phobia
Obsessive

Compulsive
Disorder
Alcohol
dependent
Drug
dependence
Schizophrenia

Your medical history


Medical Problems (please list all of your known medical condition, and
when they were first diagnosed) :
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Surgery
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Medication
Please list all medications you are currently taking, including non-prescription
drugs. Include the frequency and dose, if known
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Allergies
Drugs/Latex
:_______________________________________________________________________
Other
:____________________________________________________________________________
Your family Medical Conditions
Please specify who in your family has the following disease : consider
grandparents,parents, aunts,uncles,siblings, children, nieces,
nephew,grandchildren.
Diseases
Ye No Who?
s

Diabetes
Heart Disease
Stroke
Obesity
High Blood Pressure
Thyroid problems
High choloestrol
Substance abuse disorder
Eating disorder
(anorexia,bulimia)
Other psychological
disorder
Cancer
Others
Your Medical Conditions
Pulmonary
Smoked within the past year

Ye
s

N
o

Ye
s

N
o

Ye
s

N
o

Ye
s

N
o

Require oxygen
Had a Pulmonary Embolism/Blood clot in lung
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Use CPAP/BiPAP
Gastrointestinal
Heartburn requiring medication
Gallstones or had your gallbladder removed
Pancreatitis
Fatty Liver Disease
Previous weight loss surgery
Musculoskeletal
Back pain
Disc Disease in the back
Rheumatoid arthritis
Osteoarthritis
Musculoskeletal Disease
Limitation of activity by pain
Daily pain medication required
Surgery for joints planned
Mobility devices used (cane, walker,etc)
Renal/ Kidney
Kidney Disease
Kidney failure requiring dialysis
Urinary or stress incontinence

Kidney stone
Cardiac / Vascular
Heart attack

Ye
s

N
o

Ye
s

N
o

Ye
s

N
o

Ye
s

N
o

Cardiac catherization (stent in the heart)


Cardiac Surgery
Elevated Cholesterol
High Blood Pressure
Blood Clot in the leg (DVT)
Venous stasis
Peripheral vascular disease
Cellulitis
Family history of clot
Endocrine
Diabetes Mellitus, :(diet, oral medication, on insulin)
Insulin Resistance
Diebetic eye disease
Chronic Steroids / Immunosuppression
Gout
Thyroid disease
Polycystic ovary disease
Reproductive disorder
Neurologic
Stroke
Migraine
Pseudotumor Cerebri
Headache
Numbness
Other
Blood thinner (reason :
)
Cancer (type :
)
Rheumatologic Disorders
Your Financial Preference
Which statement below describes your financial status?
I am afford to spent <RM400/month for weight loss
supplement/program/my health (Yes/NO)
I am afford to spent >RM 400/month for weight loss
supplement/program/my health (Yes/NO)
I am afford to spend >RM800/month for weight loss
supplement/program/my health (Yes/No)

I never think about the price as long as I can achieved my body


weight goal/ regain my health (Yes/No)

I prefer to use:
Cash (Yes/No)
Debit card (Yes/No)
Credit Card (Yes/No) :(Please list name of Credit
card)________________________________

Body Composition analysis

Body weight (Kg) :


Height (cm) :
BMI :
Resting Metabolic Rate :
Body Fat analysis (%):
Visceral Fat :
Skeletal Muscle (%):
Body Fat % Classification
Gender
Age
-(Low)
0
+ (High)
(Normal)
FEMALE
20 -39
<21
21 32.9
33- 38.9
40- 59
<23
23 -33.9
34-39.9
60 -79
<24
24 -35.9
36 -41.9
MALE
20 -39
<8
8-19.9
20-24.9
40 -59
<11
11-21.9
22-27.9
60 -79
<13
13-24.9
25 -29.9
Trunk Fat %
0
+ (High)
(Normal)
<15
16 -18
Visceral Fat %
0
+ (High)
(Normal)
0.5 -9.5
10-14.5

++(Very
High)
>39
>40
>42
>25
>28
>30
++(Very
High)
>18
++(Very
High)
15- 30

Skeletal Muscle % Classification


Gender
Age
-(Low)
0
+ (High)
(Normal)
FEMALE
20 -39
<24.3
24.3-30.3
30.4-35.3
40- 59
<24.1
24.1-30.1
30.2-35.1
60 -79
<23.9
23.9-29.9
30-34.9
MALE
20 -39
<33.3
33.3-39.3
39.4-44
40 -59
<33.1
33.1-39.1
39.2-43.8
60 -79
<32.9
32.9-38.9
39-43.6
BMI
Under
Normal
Over
Weight
Weight
<18.4
18.5-24.9
25-29.9
*BMI : weight (kg) /height (m)/height (m)
Remarks :

++(Very
High)
>35.4
>35.2
>35
>44.1
>43.9
>43.7
Obese
>30