Weight & Diet Analysis

Private & Confidential

Name *
Date of birth
Date of birth
Antibiotics history
(including any surgery)
(e.g. fields sprayed with pesticide)
e.g. dry cleaning fluids, paint, varnish, solvents, sheep dip
WOMEN: Are you pregnant?
ALL: do your fingers or ankles ever get very swollen?
Does your weight ever go up or down by more than 3 lbs within a single day?
Your Eating Habits
Honesty is essential
Your Meals
Why do you think you have a weight problem?
Tick any relevant answers

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