Journey Clinic Patient Questionnaire

Since your last visit with a Doctor, have you been to the ER, had any procedures, or been admitted to a hospital? *Required

What type of exercise are you doing?

List all vitamins that you take.

Do you keep a food journal/log?

Yes No

Are you measuring your foods?

Yes No

How many grams of protein do you consume in a day?

How many meal replacements do you have daily?

1 2 3 4

What brand?

How many ounces of fluid are you drinking daily?

Do you drink liquids with meals?

Yes No

Besides your supplements, do you drink any calorie containing liquids?

Yes No

What kind?

How long does it take to eat a meal? (minutes)

How long after eating do you feel hungry? (hours)

How much food do you eat at a meal? (cups/ounces)

Does food get stuck?

Yes No

Do you vomit at least weekly?

Yes No

Aside from holiday feasts, have you ever eaten a large amount of food rapidly and felt this eating incident was excessive or out of control?

Yes No

If you answered yes above how often have you engaged in this behavior in the last year?

Have you ever purged (used laxatives, diuretics or induced vomiting) to control your weight?

Yes No

If you answered yes above how often have you engaged in this behavior in the last year?

Do you eat more than you would like to when you have negative feelings such as anxiety, depression, anger or loneliness? Choose Never Sometimes Always

Do you have trouble controlling your eating when you have positive feelings-do you celebrate feeling good by eating? Choose Never Sometimes Always

When you have unpleasant interactions with others in your life, or a difficult day, do you eat more than you’d like? Choose Never Sometimes Always

Do you think you would benefit from seeing the Psychologist?

Yes No

Please check any of the following ulcer triggers that you are using.

***Band Patients ONLY: Do you think you need Choose A fill An unfill Neither Unsure

Breakfast

Snack

Lunch

Snack

Dinner

Drinks

Are there any questions or concerns that you would like to address with the doctor specifically?