YesNo
Kg
YesNo
yes special diet
Very low calorie (less than 800 Cal/day)
High-protein/low-carbohydrate (i.e. Atkins)
Ground or pureed foods
Other
(Kg)
YesNo
YesNo
YesNo
(Kg)
(Kg)
(Kg)
(Kg)
(Kg)
yes reasons
Body metabolism/genetics
Eating disorder
Depression
Medical conditions
Appetite (I am always hungry)
Low physical activity
YesNo
YesNo
(Kg)
(Kg)
(Kg)
(Kg)
months
YesNo
YesNo
(Kg)

weeks
Weight control method Yes/No tried during past 6 months No.
1. Limitation of fat intake
2. Calorie restriction
3. Very Low-calorie diet
4. Omitting between-meal snacks
5. Sugar restriction
6. Cut out non-diet soda pop or other sugar-sweetened beverages
7. Carbohydrate restriction (rice, bread, potato)
8. Having more fruits and vegetables
9. Smoking cigarettes for weight loss
10. Illicit drugs use for weight loss (amphetamines, LSD, etc.)
11. Documenting daily food intake
12. Keeping a graph of your weight
13. Documenting daily physical activity
14. Increasing physical activity
15. Using exercise equipment
16. Group exercise activities/yoga
17. Chewing and spitting food
18. Inducing vomit after meals
19. Use of laxatives
20. Hypnotism for weight loss
21. Using prescription medication
22. Alterative medical drugs/ herbal
23. Acupuncture


YesNo

status value
1. I eat more when angry
2. I eat more when depressed
3. I eat more when tired and bored
4. I eat more when happy
5. I am the first person to finish my food when with others
6. I constantly eat food during its preparation
7. I enjoy preparing food
8. I feel an urge to finish my plate
9. I eat more in travel with certain people
10. Most of my family and friends have a connection with food preparation and cooking
11. I pay more attention to surrounding than my food, when eating
12. I have to eat outside because of my job
13. I can’t help eating in parties
14. I can’t help eating when too hungry
15. I usually feel guilty because of the quantity of my meals
16. I eat more when stressed or anxious
17. I force myself to vomit or take laxatives when I eat too much
18. I rarely eat fruits and vegetables
19. I usually eat desserts
20. I usually eat fried food
21. I rarely have steamed or boiled food
22. I think I should spend a lot of time for eating healthy
location Breakfast(days/week) lunch dinner
Fast food restaurants
Other restaurants
yes Specialty how many times?
Nutrition specialist
Consultant/ psychiatrist
Sport specialist