Can you create a comprehensive lifestyle‑intervention intake questionnaire for a patient enrolling in a weight‑management program?

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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:
    • LS ≥50: 90.7% report successful weight loss; 5% report weight regain 8
    • LS <0: 35.7% report weight loss success; 39.4% report weight regain 8
  • Mean LS by outcome:
    • Successful weight loss: mean LS = 26.92 (SD 17.03) 8
    • Unsuccessful: mean LS = 13.68 (SD 14.95) 8
    • Healthy BMI: mean LS = 22.2 (SD 15.51) 8
    • Obese BMI: mean LS = 6.70 (SD 15.97) 8

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:
    • Women: 1,200–1,500 kcal/day 1, 6, 2
    • Men: 1,500–1,800 kcal/day 1, 6, 2
    • Alternative: 500–750 kcal/day deficit from baseline intake 1, 6
  • Physical activity target:
    • Initial: 150 minutes/week moderate-intensity activity 6, 2
    • Maintenance: 200–300 minutes/week 6, 2
  • 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

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Comprehensive Lifestyle Interventions in Psychiatry for Weight Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Pretreatment predictors of attrition and successful weight management in women.

International journal of obesity and related metabolic disorders : journal of the International Association for the Study of Obesity, 2004

Research

Who will lose weight? A reexamination of predictors of weight loss in women.

The international journal of behavioral nutrition and physical activity, 2004

Guideline

Weight Loss Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Metrics for weight management success: an examination of the lifestyle score.

Health psychology and behavioral medicine, 2024

Guideline

Referral and Management of Morbid Obesity: Evidence‑Based Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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