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

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)
Heart attack
Congestive heart failure
High cholesterol

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
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


XENICAL is a prescription medicine used with a low calorie diet to increase weight loss in people with obesity. XENICAL may help obese people lose weight and keep the weight off.

It is not known if XENICAL is safe and effective in children under 12 years old.

Important Safety Information

Do not take XENICAL if you: Before you take XENICAL, tell your doctor if you:
Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements.

Especially tell your doctor if you are taking:

XENICAL may cause serious side effects, including:
The most common side effects of XENICAL include:
*Oily discharge may be clear or have an orange or brown color.

How should I take XENICAL?
Take XENICAL with a nutritionally balanced, low calorie diet that has no more than about 30% of calories from fat. Taking XENICAL with any meal high in fat (more than 30% fat) may make the common side effects worse.

If you take too much XENICAL call your doctor or go to the nearest hospital emergency room right away.

These are not all the possible side effects of XENICAL. For more information, ask your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Click here for Important Patient Information.