Personal Weight-Loss Worksheet

This worksheet can help facilitate a productive discussion with your doctor about your weight-loss goals and options. The information you provide on this worksheet will help your doctor determine the weight-loss approach that is right for you.

To use the worksheet, just print it out, fill it in and take it with you to your doctor appointment.

Basic Information

How tall are you? ___ feet ___inches
How much do you weigh? ____
What is your Body Mass Index (BMI)? ___
(To determine your BMI, use the BMI Calculator at www.xenical.com)

Weight-Loss Goals

How much weight would you like to lose? (check one)
10–20 lbs
21–40 lbs
More than 40 lbs

Why would you like to lose weight? (check all that apply)
I’d like to improve my health.
I’d like to look better.
Other ______________________________________.

Weight-Loss History

How do you feel about yourself and your current weight? (please describe below)






What weight-loss methods have you tried before? (check all that apply)
Reduced-calorie diet
Reduced-carbohydrate diet
Reduced-fat diet
Diet programs and support groups
Physical activity
Over-the-counter diet pills
Prescription weight-loss medications

How would you describe your experiences with the weight-loss methods you’ve listed above? (describe below)

Medical History

Do you or any of your family members have, or have you or they had, any of the following medical conditions or illnesses? (check all that apply)
Diabetes
Heart attack
Congestive heart failure
Stroke
Arthritis
Asthma
Cancer
High cholesterol
Hypothyroidism

Physical Activity

How often do you engage in physical activities?
Every day
Three or more times a week
Once a week
Once or twice a month
Never
I am not able to engage in physical activity for the following reason(s): (describe below)

Weight-Loss Options

Which of the following weight-loss options are you interested in pursuing? (check all that apply)
A healthy eating plan
Appropriate physical activity
Prescription medication options