Comprehensive Lifestyle Intervention Intake Questionnaire for Weight Management Program
Use this structured intake questionnaire to systematically assess all domains required by AHA/ACC/TOS guidelines for patients enrolling in a weight management program, capturing baseline behavioral, psychosocial, and clinical data that predict treatment success and guide individualized intervention planning. 1
Section 1: Anthropometric & Clinical Measurements
Measure and document at intake:
- Height, weight, and calculated BMI (kg/m²) 1
- Waist circumference at the level of the iliac crest 1
- Blood pressure (seated, after 5 minutes rest; document orthostatic changes if indicated) 2
- Baseline vital signs including resting heart rate 2
Laboratory orders to obtain:
- Fasting lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides) 2, 3
- Fasting glucose and hemoglobin A1c 2
- Comprehensive metabolic panel 2
- Complete blood count 2
- ECG if patient has restrictive eating history, severe purging behaviors, or takes QTc-prolonging medications 2
Section 2: Medical & Weight History
Document the following:
- Number of previous weight loss attempts in the past 12 months (≥3–4 prior diets in one year predicts poorer outcomes) 4, 5
- Maximum lifetime weight and lowest adult weight 1
- Age at onset of overweight/obesity 1
- Pattern of weight change over time (gradual vs. rapid gain; cyclical weight loss/regain) 1
- Current medications (especially antipsychotics, antidepressants, corticosteroids, antidiabetic agents) 2
- Obesity-related comorbidities: type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, osteoarthritis, GERD, NAFLD 1
- Family history of obesity, diabetes, cardiovascular disease 1
Section 3: Dietary Assessment
Capture baseline eating patterns:
- Estimated daily caloric intake (use 24-hour recall or 3-day food diary) 1
- Macronutrient distribution: percentage of calories from carbohydrates, protein, fat 1
- Fiber intake (grams per day; low fiber intake predicts attrition) 4
- Frequency of meals and snacks per day 1
- Eating window duration (hours per day of food consumption vs. fasting) 6
- Consumption of sugar-sweetened beverages, fast food, processed foods (frequency per week) 1
- Fruit and vegetable servings per day 2
- Whole grain intake (servings per day) 2
- Current use of meal-tracking apps or food diaries 1
- Time and resources available for meal preparation (hours per week; access to kitchen facilities) 1
- Use of commercial meal programs or meal-delivery services 1
Section 4: Physical Activity & Exercise Evaluation
Assess current activity level and barriers:
- Average steps per day (use pedometer or smartphone data if available) 1
- Minutes per week of moderate-intensity aerobic activity (e.g., brisk walking) 1, 6
- Minutes per week of vigorous-intensity activity 6
- Resistance/strength training sessions per week 1
- Types of physical activities the patient finds enjoyable (walking, swimming, cycling, group classes, etc.) 1
- Access to exercise facilities (gym membership, home equipment, safe outdoor spaces) 1
- Physical limitations: joint disease (osteoarthritis of knees/hips), previous injuries, chronic pain, mobility impairment 1
- Cardiorespiratory fitness level (if exercise specialist assessment available; stress test not required unless CVD suspected) 1
- Sedentary time per day (hours spent sitting/screen time) 1
Section 5: Psychosocial & Behavioral Assessment
A. Weight Management Self-Efficacy
Administer the Weight Efficacy Lifestyle Questionnaire Short-Form (WEL-SF):
- Score range: 0–80 points 1
- Interpretation: Total score >53 indicates higher self-efficacy and motivation for positive lifestyle changes 1
- Action: Scores ≤53 warrant referral to a behavioral health professional experienced in obesity counseling 1
B. Eating Triggers & Patterns
Screen for:
- Emotional eating triggers: anxiety, depression, stress, boredom, fatigue, loneliness 1
- Binge eating behaviors: recurrent episodes of eating large amounts in short periods with loss of control 1
- Night eating syndrome: >25% of daily calories consumed after dinner 1
- Restrictive eating or compensatory behaviors (purging, excessive exercise, laxative use) 2
- Body image disturbances: dissatisfaction with appearance, avoidance of mirrors/photos, social withdrawal due to weight 1
Action: Patients with binge eating, body image disturbances, or maladaptive eating patterns require referral to a mental health provider, preferably an eating disorders specialist 1, 2
C. Depression Screening
Administer the Patient Health Questionnaire-9 (PHQ-9):
- Score range: 0–27 1
- Interpretation: Scores ≥10 indicate moderate-to-severe depression requiring clinical attention 1
- Action: Depression is common in obesity; positive screens necessitate psychiatric evaluation and treatment 1
D. Quality of Life
Assess:
- Health-related quality of life using validated instruments (e.g., SF-36 or obesity-specific QOL measures) 4
- Impact of weight on daily functioning: mobility, self-care, work performance, social activities 4
Note: Poorer baseline quality of life predicts higher attrition rates 4
E. Weight Outcome Evaluations & Expectations
Document patient's weight loss goals and expectations:
- Target weight or BMI 4, 5
- Timeframe for achieving goal weight 4, 5
- Minimum acceptable weight loss (what would patient consider "success") 4, 5
- Maximum acceptable weight loss (what would make patient "happy") 4, 5
Critical finding: Very accepting evaluations (willing to accept minimal weight change) predict poor outcomes; extremely demanding evaluations also predict attrition. Moderate, realistic expectations (5–10% weight loss over 6 months) predict best success. 4, 5
F. Motivation & Readiness for Change
Assess using the Transtheoretical Model stages:
- Precontemplation (not considering change)
- Contemplation (thinking about change)
- Preparation (planning to change soon)
- Action (actively making changes)
- Maintenance (sustaining changes) 2
Action: Patients in precontemplation/contemplation stages require motivational interviewing and may not be ready for intensive intervention; periodically reassess readiness 2
G. Self-Monitoring Practices
Current use of:
- Daily self-weighing (frequency per week) 6, 7
- Food intake tracking (paper diary, app, photos) 6, 7
- Physical activity logging (step counts, exercise minutes) 6, 7
Note: Regular self-monitoring is a core behavioral strategy; baseline use predicts adherence 6, 7
H. Social Support & Environment
Assess:
- Household composition: who lives with patient; do household members support weight loss efforts 1
- Family/friend support for lifestyle changes (encouragement vs. sabotage) 1
- Work schedule and shift work (irregular hours impair meal planning and sleep) 1
- Access to healthy food: proximity to grocery stores vs. fast food outlets 1
- Financial resources for program participation (ability to afford healthy foods, gym membership, program fees) 1
Section 6: Lifestyle Score Calculation (Optional)
Administer the Lifestyle Questionnaire for Weight Management (LQ-WM):
- Lifestyle Score (LS) range: –49 to +77 8
- Interpretation:
- Mean LS by outcome:
Action: Use LS to raise patient awareness of behavioral patterns and predict likelihood of success; lower scores indicate need for more intensive support 8
Section 7: Barriers & Facilitators Checklist
Identify specific barriers:
- Time constraints (work hours, caregiving responsibilities) 1
- Financial limitations 1
- Lack of social support 1
- Medical comorbidities limiting activity 1
- Psychological barriers (low self-efficacy, depression, anxiety) 1, 4
- Environmental barriers (food deserts, unsafe neighborhoods) 1
- Cultural or religious dietary restrictions 1
Identify facilitators:
- Strong intrinsic motivation 4, 5
- High exercise self-efficacy 4
- Supportive household members 1
- Access to exercise facilities and healthy food 1
- Previous success with short-term weight loss 4
- Moderate, realistic weight loss expectations 4, 5
Section 8: Program Preferences & Logistics
Document patient preferences:
- Preferred intervention format: individual vs. group sessions 7
- Preferred delivery modality: in-person, telephone, internet/app-based, hybrid 6, 7
- Availability for sessions: days/times that work with patient's schedule 1
- Interest in commercial programs (e.g., Weight Watchers, Jenny Craig) with peer-reviewed efficacy data 6
- Interest in meal replacements or structured meal plans 1
- Interest in pharmacotherapy (if BMI ≥27 with comorbidities or BMI ≥30) 1
- Interest in bariatric surgery evaluation (if BMI ≥40 or BMI ≥35 with comorbidities) 9
Section 9: Baseline Goal-Setting
Establish initial treatment goals collaboratively:
- Weight loss target: 5–10% of initial body weight over 6 months 1, 6, 2
- Rate of weight loss: 0.5–1 kg (1–2 pounds) per week 2
- Caloric prescription:
- Physical activity target:
- Self-monitoring frequency: daily food logging, weekly self-weighing 6, 7
- Session attendance: weekly for first 6 months (≥14 sessions = high-intensity intervention) 1, 6, 7
Section 10: Referral Planning
Based on intake findings, arrange referrals:
- Registered Dietitian Nutritionist (RDN): Class I, Level A recommendation for all patients; required when prescribing calorie-restricted diets 9
- Behavioral health specialist: for WEL-SF score ≤53, PHQ-9 ≥10, binge eating, body image disturbances, or eating disorders 1, 9, 2
- Exercise specialist or physical therapist: for patients with mobility limitations, joint disease, or need for supervised fitness assessment 1, 9
- Bariatric surgeon: for BMI ≥40 or BMI ≥35 with comorbidities who have not responded to behavioral treatment (Class I, Level A recommendation); simultaneous referral to RDN and surgeon is appropriate 9
- Sleep medicine: if obstructive sleep apnea suspected 1
- Endocrinology: for uncontrolled diabetes or thyroid disorders 1
Do not delay specialist referrals; obesity is a chronic disease warranting early multidisciplinary involvement. 9
Common Pitfalls to Avoid
- Failing to assess previous dieting history: ≥3–4 diets in the past year strongly predicts attrition and poor outcomes 4, 5
- Ignoring unrealistic weight expectations: both overly accepting and excessively demanding expectations predict failure; counsel patients toward moderate 5–10% goals 4, 5
- Omitting psychosocial screening: depression, low self-efficacy, and poor quality of life are modifiable barriers that require intervention 1, 4
- Prescribing diet alone without physical activity and behavioral therapy: comprehensive lifestyle intervention (all three components) is more effective than isolated dietary counseling 9, 2
- Delaying referral to RDN or bariatric surgery: early involvement of specialists improves outcomes 9
- Underestimating the importance of self-monitoring: baseline use of food diaries and self-weighing predicts adherence 6, 7
Expected Outcomes & Follow-Up
- At 6 months: expect 4–12 kg weight loss (approximately 8% of initial weight) with high-intensity intervention 7
- Clinically meaningful benefits occur with 3–5% weight loss: reductions in triglycerides, fasting glucose, HbA1c, and diabetes risk 1, 9
- Greater benefits with 5–10% loss: improved blood pressure, LDL-C, HDL-C, and reduced medication needs 1, 9
- Long-term maintenance: transition to monthly or more frequent contact for ≥12 months to prevent weight regain of 1–2 kg/year 6, 2, 7