Center for Lifestyle Medicine Initial Assessment

Center for Lifestyle Medicine Initial Assessment
259 East Erie Street, Suite 1600 | 312.695.2300 | 312.926.6068 (fax)

Name:________________________________________________ Date: ____________________________

BACKGROUND QUESTIONS

Preferred phone:______________________________________ E-mail:______________________________________________

Occupation:___________________________________________ Work hours: _________________________________________

Marital Status (please check):

Single

Married

Divorced

Widow

Partnered

Please list names of the people in your household and their relationship to you:

_____________________________________________________ ____________________________________________________

_____________________________________________________ ____________________________________________________

Do you own a family dog?

Yes

No

What is the highest level of education completed? ________________________________________________________________

What prompted you to seek services at this time? _________________________________________________________________

What are your personal goals we can help you achieve?____________________________________________________________

OVERALL HEALTH QUESTIONS

Primary care provider:_______________________________________________________ Phone: ____________________________

Address:______________________________________________________________________________________________________

When was your last physical exam?__________________________ When did you last have blood tests? ___________________

How would you rate your health? (please check):

Excellent

Good

Fair

Poor

Height: __________________ Weight: __________________

Continued >

page 1

Center for Lifestyle Medicine Initial Assessment (continued)

PAST MEDICAL HISTORY Mark (x) all that apply:

Acid Reflux (GERD) Anemia Anorexia Anxiety Arthritis Asthma/Lung Problem Attention Deficit Disorder Bipolar Disorder Bleeding Disorders Blood clot/DVT Bulimia Cancer Celiac Disease Congestive Heart Failure Drug/Alcohol Dependency Depression Diabetes (Type 1)

Diabetes (Type 2) Emphysema/Chronic Bronchitis Epilepsy/Seizure Disorder Fatty Liver Disease Gallbladder Disease/Stones Glaucoma Gout Heart Disease/Heart Attack Heart Murmur Hepatitis High Blood Pressure/ Hypertension High Cholesterol HIV Disease Irregular Menstrual Periods Impaired Fasting Glucose/ Pre-Diabetes

Kidney Disease Liver Disease Migraines Multiple Sclerosis Obsessive Compulsive Disorder Osteoporosis/penia Polycystic Ovarian Syndrome (PCOS) Pacemaker Prostate Problem Sickle Cell Disease Sleep Apnea Stroke Thyroid Disease Tuberculosis Ulcer Disease Other

REVIEW OF SYSTEMS Mark (x) all that apply:

GENERAL RESPIRATORY CARDIAC GASTROINTESTINAL
GENITOURINARY

Fever/chills Fatigue
Excessive shortness of breath Coughing Wheezing
Chest pain Irregular heart beat Palpitations
Indigestion/heartburn Nausea/vomiting Abdominal pain Hemorrhoids
Difficulty urinating Urinary incontinence Inability to empty bladder fully Abnormal menstrual period

Weakness Low energy level
Snoring Daytime sleepiness Disturbed sleep
Ankle or feet swelling Varicose veins
Diarrhea Constipation Change in bowel habits Rectal bleeding
Recurrent urinary infections Infertility Sexual problems Frequent urination
Continued >
page 2

Center for Lifestyle Medicine Initial Assessment (continued)

REVIEW OF SYSTEMS (continued) Mark (x) all that apply:

MUSCULOSKELETAL ENDOCRINE NEUROLOGIC SKIN PSYCHOLOGICAL

Back pain Joint pain Difficulty walking
Excessive thirst Excessive/increased urination
Headaches Seizures Tremors
Infection (boils, ulcers, etc) Chronic rashes Acne
Lack of interest in doing things Feel down, depressed or hopeless

Muscle cramps Muscle weakness
Cold/heat intolerance Blurry vision
Dizziness Numbness Tingling
Abnormal bruising Excessive hair growth (females) Changes in skin color
Anxious History of physical violence/abuse

Average hours of sleep each night _________________________________________ Is sleep refreshing?

Yes

No

How would you rate your stress level? low 1

2

3

4

5 high

How do you cope with daily stressors? ___________________________________________________________________________

Are you currently seeing a mental health professional?

Yes

No

If yes, please provide name and contact information:______________________________________________________________

List all previous surgeries with date: ____________________________________________________________________________

_____________________________________________________________________________________________________________

List your current medications and dosages. Include any vitamins and supplements:

1. ___________________________________________________ 5. __________________________________________________

2. ___________________________________________________ 6. __________________________________________________

3. ___________________________________________________ 7. __________________________________________________

4. ___________________________________________________ 8. __________________________________________________

Do you have any allergies to medications? _______________________________________________________________________

Continued > page 3

Center for Lifestyle Medicine Initial Assessment (continued)

Preventive care screenings and diagnostic tests you have had (please check and provide the date):

Sigmoidoscopy/Colonoscopy_________________

Pap Smear _____________________________

Cardiac Stress Test _________________________

Mammogram ___________________________

Bone Density______________________________

Prostate/Testicular Exam _______________

Tobacco history (please check):

Never Smoked

Past Smoker

Current Smoker

Alcohol history (please check):

Do Not Drink

Currently Drink ________ drinks per week

Recreational drug use (please check): Never

Past User

Present User

FAMILY HEALTH HISTORY:

RELATION

AGE

Father Mother Siblings

MEDICAL CONDITIONS

OVERWEIGHT OR OBESE?

AGE AT DEATH

Spouse Children

Continued > page 4

Center for Lifestyle Medicine Initial Assessment (continued)

NUTRITION QUESTIONNAIRE
What one or two things would you like to change about your diet?___________________________________________________ Do you read food labels? If yes, what do you look for?_______________________________________________________________ How confident are you about the amount of current nutrition knowledge you have? low 1 2 3 4 5 high How confident are you about your ability to apply the nutrition knowledge you have? low 1 2 3 4 5 high Do you have any food allergies? _________________________________________________________________________________ Do you follow any special diet or dietary restrictions? ______________________________________________________________ When and what do you usually eat over the course of a typical day? (Please list in table below):

MEAL Breakfast Snack Lunch Snack Dinner Snack

TIME __________________ __________________ __________________ __________________ __________________ __________________

FOODS EATEN _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

What do you drink throughout the day? ___________________________________________________________________________

How many meals per week do you eat in restaurants/order takeout? _________________________________________________

Do you eat much more rapidly than others?

Yes

No

Do you eat until feeling uncomfortably full?

Yes

No

Do you eat large amounts of food when you are not feeling physically hungry?

Yes

No

Do you feel disgusted with oneself, depressed, or very guilty after overeating?

Yes

No

Do you eat alone because of being embarrassed by how much you are eating?

Yes

No

Do you have a history of an eating disorder? (If yes, please check):

Compulsive Overeating

Binge Eating Disorder

Anorexia

Bulimia

Do you feel that you have a food addiction (loss of control over food intake)?

Yes

No

Continued >

page 5

Center for Lifestyle Medicine Initial Assessment (continued)

PHYSICAL ACTIVITY QUESTIONNAIRE

What is the most active thing you do in an average day? ____________________________________________________________

What, if any, regular exercise do you participate in and how often? ___________________________________________________

In general, how much do you enjoy doing physical activity?__________________________________________________________

low enjoyment 1

2

3

4

5 high enjoyment

What makes it difficult for you to exercise? ________________________________________________________________________

Do you know any other reason why you should not do physical activity?

Yes

No

When you exercise or exert yourself, do you have any of the following? (please check if yes)

Shortness of breath

Chest pain or pressure

Pain in your calves

WEIGHT HISTORY

What was your lowest body weight as an adult? _________________________ lbs. At what age?_________________________

What was your highest body weight as an adult? _________________________ lbs. At what age?________________________

Have you previously participated in a commercial or professional weight loss program?

Yes

No

(If yes, please check all programs):

Weight Watchers

Jenny Craig

NutriSystem

Women’s Workout World

Very Low Calorie Diet

Weight Loss Medication ___________________________
(name of medication)

Other ________________________________________

Have you previously seen a Registered Dietitian (RD)?

Yes

No

Have you ever had weight loss surgery? If so, which one and when? _________________________________________________

What is the maximum amount of weight you’ve lost in the past? _________________________ lbs.

What are the biggest challenges you face in losing weight/maintaining weight loss? __________________________________

______________________________________________________________________________________________________________

How important is it for you to make lifestyle changes?

very important 1

2

3

4

5 not important

How confident are you in your ability to make lifestyle changes?

very confident 1

2

3

4

5 not confident

Continued > page 6

WEIGHT -
WEIGHT -
WEIGHT -

Center for Lifestyle Medicine Initial Assessment (continued)

Graphing your weight gain Below are examples of typical weight gain patterns according to life events.

Progressive (or Ratcheting) Weight Gain

- College -

Stressful job

Death in family

TIME

Weight Cycling or “Yo-Yo” Weight Gain

-

Divorce

-

Pregnancy

- Marriage

-

- Joined

-

Initiated commercial

- Isneiltfiadtieetd self diet program

TIME

Inciting Event Weight Gain

- Living away - from home -

Illness or physical injury
TIME

Using the examples as a reference, please graph your weight gain. Mark life events and diet attempts that may have contributed to your current weight.

Weight (pounds)

Time (age or year)

Continued >

page 7

Center for Lifestyle Medicine Initial Assessment (continued)

SIX-FACTOR TRAIT QUESTIONNAIRE (6-FTQ) Please check your level of agreement to all statements:

Don’t agree Agree

at all

a little

Agree

CONVENIENT DINER

Strongly agree

1. I rarely take the time to plan my meals.

0

1

2

3

2. A lot of my meals are eaten in restaurants or taken out.

0

1

2

3

3. Most foods I eat are convenient, ready- made, packaged, frozen or microwavable.

0

1

2

3

4. I eat a fast-food meal on most days of the week.

0

1

2

3

5. I do not have consistent meal patterns from one day to the next.

0

1

2

3

Sub score

FAST PACER

6. My fast-paced life leaves me feeling drained and scattered.

0

1

2

3

7. I feel like I’m juggling too many things at once.

0

1

2

3

8. I usually take care of everyone else and put myself at the bottom of my to-do list.

0

1

2

3

9. My hectic schedule makes it hard for me to focus on my health.

0

1

2

3

Sub score

EASILY ENTICED EATER

10. I have difficulty controlling my portion sizes.

0

1

2

3

11. I often eat out of habit, not because I am hungry.

0

1

2

3

12. When I’m stressed, lonely, anxious or depressed, I turn to food for comfort.

0

1

2

3

13. If there is food around me, I’ll probably eat it.

0

1

2

3

14. I snack throughout the day, hungry or not.

0

1

2

3

15. I will eat until I’m too full – and may even eat more.

0

1

Sub score

2

3

Continued >

page 8

Center for Lifestyle Medicine Initial Assessment (continued)

SIX-FACTOR TRAIT QUESTIONNAIRE (6-FTQ) Please check your level of agreement to all statements:

Don’t agree at all

Agree a little

Agree

EXERCISE STRUGGLER

16. Of all things being physically active has never been one of my priorities.

0

1

2

17. I don’t exercise because frankly I don’t like it.

0

1

2

18. I never got “into” exercising because I am not sure where to start.

0

1

2

19. I have difficulty exercising.

0

1

2

Sub score

SELF-CRITIC

20. I measure my self-worth by the numbers on the bathroom scale.

0

1

2

21. I focus on the things I don’t like about my body.

0

1

2

22. I make a habit of saying bad things about myself.

0

1

2

23. I avoid social situations because of my weight.

0

1

2

Sub score

ALL-OR-NOTHING DOER

24. I approach my weight loss like it’s just another project with a clear beginning and end.

0

1

2

25. I’m either on or off my diet – there’s no middle ground with me.

0

1

2

26. When I’m trying to lose weight, I give 100% of my effort but this is hard to sustain.

0

1

2

27. I am all or nothing when it comes to dieting or exercising to lose weight.

0

1

2

Sub score

Strongly agree
3 3 3 3
3 3 3 3
3 3 3 3

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