Obesity History

Yes

No

1) Has your doctor ever diagnosed you with pre-obesity or obesity?

2) Has your doctor ever prescribed medication for obesity or pre-obesity?

3) Have you ever had bariatric surgery?

4) Have you ever had any cosmetic procedures for obesity (liposuction)?

5) Have you ever had obesity-related complications (insulin resistance, obstructive sleep apnea, etc.)?

6) Do you have conditions that promote obesity (hypothyroidism)?

7) Are you taking medications that promote obesity (antipsychotics)?

8) Has obesity impaired your activities of daily living (work, moving)?

9) Has your doctor referred you to a registered dietician or nutritionist?