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Chicago Weight Intake Questionnaires

Please complete the health-screening questionnaire at home, ideally 1-2 weeks before the visit and bring it with you on the day of your appointment.  Do take time and put real thoughts into your answers. This information will be crucial to your initial assessment and the planning of your individualized treatment plan. The questionnaires below that are PDFs may take a moment to download. Please note that if you are using the Firefox browser, you may need to print the PDFs and complete them manually. 

Health History Questionnaire (printable version)

Health History Questionnaire (electronic version) - use this exclusively if you are planning to complete the questionnaire on your computer - it can be printed or emailed to Silvana Pannain, MD, at

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