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Name
   
 
 
 
Age
 
 
 
Gender
 
Male
 
Female
 
 
 
Occupation
 
 
 
Weight
 
 
 
Height
 
 
 
BMI
 
 
 
Waist to hip ratio (WHR)
 
 
 
Were you overweight as a child?
 
Yes
 
No
 
 
 
In your opinion, what contributes to your excess weight?
 
Portion size
 
Compulsive eating
 
Lack of exercise
 
Stress
 
Nervous eating
 
Emotional eating
 
Eating too much fat & sugar

 
 
 
Why do you eat?
 
Hunger
 
Stress
 
Guilt
 
Boredom
 
Enjoy the taste
 
Depression
 
Anger

 
 
 
What aspects of life are getting affected due to your excess weight?
 
Daily activities
 
Ability to exercise
 
Ability to perform job duties
 
Ability to participate in social activities
 
Toll on married/sexual relationship
 
Affect on relationships with friends
 
Affect on self-esteem
 
None

 
 
 
Do you eat when you are not hungry?
 
Yes
 
No
 
 
 
Do you have trouble telling the difference between true hunger and just want to eat?
 
Yes
 
No
 
 
 
What would be the advantages of losing weight for you?
 
Look better
 
Be more attractive
 
Clothes fit better
 
Happier
 
Don't feel self-conscious in public
 
Healthier
 
Live longer
 
More energetic
 
Feel in control
 
More confident
 
Boost self-esteem
 
Won't have to listen to family and friends comment on eating habits

 
 
 
How committed are you to making this weight change in your life with this program right now?
 
Extremely committed
 
Very committed
 
Somewhat committed
 
 
 
What methods of losing weight have you tried in the past?
 
Exercise
 
Diet
 
Acupuncture
 
Weight loss medication
 
Behavioral treatments
 
Surgeries
 
None
 
Other
 

 
 
 
Do you have any of the following disorders?
 
Gout
 
Arthritis
 
Diabetes
 
Hypertension
 
High cholesterol
 
Hair loss
 
Varicose veins
 
Thyroid disease
 
Urinary incontinence
 
Poor liver function
 
GERD
 
Peptic ulcer
 
Gallstones
 
Cancer
 
Hypoglycemia
 
Heart condition
 
PCOD
 
Asthma
 
Anemia
 
Clotting/bleeding disorders
 
Sleep Apnea
 
Erectile dysfunction
 
BP
 
None
 
Other
 

 
 
 
Loss in weight after 20 days of acupuncture? (In KG's)
 
0-1
 
1-2
 
2-3
 
3-4
 
4-5
 
5-6
 
6-7
 
7-8
 
8-9
 
9-10
 
10 or more
 
 
 
Loss in inches after 20 days of acupuncture?
 
0-1
 
1-2
 
2-3
 
3-4
 
4-5
 
5-6
 
6-7
 
7-8
 
8-9
 
9-10
 
10 or more
 
 
 
BMI (After acupuncture)
 
 
 
Waist to hip ratio (WHR) - After acupunture
 
 
 
Effectiveness of treatment
 
Excellent
 
Good
 
Average
 
Poor
 
 
 
Methods used in addition to acupuncture?
 
Exercise
 
Diet
 
Weight-loss medication
 
None