Lifestyle and Metabolic Medicine

Transcription

1 Lifestyle and Metabolic Medicine Demographics First Name Date of Birth / / Mailing Address City, State, Zip code Preferred phone Secondary phone address Referred by Primary Care Physician New Patient Intake Form Middle Initial Age Last Name Gender Male Female ( ) - Home Work Mobile ( ) - Home Work Mobile Medical History Please list all current medications & supplements (including dosages) Are you currently being treated for, or do you have, any of the following medical conditions/markers? Check all that apply. Hyptertension or BP >130/85 Obesity (BMI >30 or waist >40in for men; >35in for women) Prediabetes Impaired Fasting Glucose Diabetes Gestational Diabetes PCOS HDL <40 for men; <50 for women Triglycerides >150 High Cholesterol or LDL Gout Fatty Liver Coronary artery disease Stroke/TIA Acid Reflux/Gerd IBS Skin tags, acanthosis, or acne Peripheral Edema Obstructive Sleep Apnea Asthma Arthritis Cancer Testosterone deficiency/male hypogonadism Hypothyroid Hyperthyroid

2 Have you ever had bariatric surgery or other weight-loss procedure(s)? Yes No If yes, please provide procedure(s) and dates performed. Procedure: Date: Have you ever been prescribed medication for weight-loss? Yes No If yes, please explain. Would you ever consider taking prescription drugs for weight-loss/management? Yes No Weight History Current Weight: Usual Weight Range: Goal Weight: Have you recently lost or gained weight? Yes No If yes, please explain. Have you ever had an eating disorder? Yes No If yes, please explain. What is your primary reason for wanting to lose weight? When did you begin gaining excess weight? (Provide reason(s), if known): What has been your heaviest weight? (non pregnant weight for females): Previous Diets You Have Followed: Dates & Results of Weight-Loss:

3 What do you feel has prevented you from reaching your weight-loss goals in the past? (ie. What about other diets/nutrition plans you have used did not work for you?) Metabolic Focused Family Medical History Have any of your family members ever been diagnosed with any of the following? If yes, who? Obesity Pre-Diabetes Diabetes Heart Attack/Heart Disease Stroke Hypertension High Cholesterol Gynecology History (*Female patients only) Menstrual Problems: Date last menstruated: Period every days No. of pregnancies Heavy Periods YES NO Irregular Periods YES NO Infrequent Periods YES NO No. of miscarriages Painful Periods YES NO Infertility issues? YES NO Nutrition History Do you have any adverse food reactions (intolerances and/or allergies)? Yes No If yes, please explain. Do you avoid certain foods? Yes No If yes, please explain. Have you ever changed your eating habits for a health reason? Yes No If yes, please explain. Have you ever changed your eating habits for any non-health related reason? Yes No If yes, please explain.

4 Current Nutrition Habits Are you currently following a particular diet or nutrition plan? Yes No If yes, please explain. How many meals do you eat per day? How many snack do you eat per day? How many meals per week do you eat out (restaurants, fast food, deli's, etc )? How many sweetened beverages (ie. Soda/softdrinks, sweetened teas, juice, flavored coffees (vanilla, carmel, mocha, etc ), energy drinks, etc do you drink per week? Are there any particular foods you crave regularly? Yes No If yes, please explain. Are there any foods that once you start eating them, you find it difficult to stop even when full? Yes No If yes, please explain. Check all facotors that apply to your current eating habits and lifsetyle: Love to eat Eat beyond fullness Emotional eater Erratic eating patterns Feel "guilty" after eating certain foods and/or eating too much. Feel confused about food/nutrition Do not plan meals or menus Rely on convenience foods Eat fast food frequently Time constraints Travel frequently Live alone/eat alone often Eat late at night Eat even when not hungry Eat while watching TV Always eat while doing something else Crave something sweet after meals Eat the same foods everyday Don't know how to cook Dislike to cook Dislike grocery shopping

5 What are your biggest obstacles when it comes to making nutrition and lifestyle changes? Please explain. How many glasses of water do you drink per day? Please describe what you eat and drink on a typical day (be specific w/ foods & time of day) Breakfast Lunch Dinner Snack(s) (E.g. 7am - 2 eggs, 1 slice whole wheat toast w/ butter and jam. Coffee with half & half.) #1: #2: #3/dessert?

6 Physical Activity Questionnaire Do you engage in regular physical activity? Yes No If yes, please complete the table below. Activity Minutes per session Number of Days/Week Are you interested in becoming more physically active? Yes No If yes, please explain any physical limitations you may have. Lifestyle Changes Preparedness What is your definition of "health"? (ie. What does "being healthy" mean to you?) What is not working in your life right now in regards to your own health and well-being? How will your life be different when you have achieved the health and well-being you desire? On a scale of 1-5 how prepared are you to invest the time and finances needed to make long-term lifestyle changes? (1=Not Ready; 5=100% ready and committed!) Goals - Please describe your top 3 goals and how you hope this program will help you accomplish them.

7 #1: #2: #3: How can we be of service to you in helping you achieve your goals? Social History Relationship Status: Single Married Divorced Other Children/Dependents: How many? Ages Religion: Employment: FT PT Where: Position: Besides children, do you care for anyone else in your home? (ie. Elderly parent/relative, individual suffering from a disability, etc.)

8 Hobbies: Please list any/all hobbies you engage in on a regular basis (eg. Reading, cooking, knitting, hiking, playing a musical instrument, etc.) SMOKING: Packs per day Pipe ALCOHOL: Drinks per day No. of years Cigar Drinks per week Year Stopped Chew Alcohol Problem? YES NO Financial Disclosure & Late Cancellation/No Show Policy: The Primal Pathway Program through the Lifestyle & Metabolic Medicine department is largely covered by your insurance, however, there is a one time program fee of $ due upon registration for the program. This one time fee covers non-insurance based costs such as program materials, access to our private Facebook page, discount codes to local fitness events, etc. Additionally, the fee provides you with one "noshow" and one "late cancel" (i.e. 24 hours or less notification) for an appointment with Dr. Sharp and Jasmine. Any future visits where there is less than 24-hours notice of cancellation will be subject to a "no-show/late cancel" fee. I,, have read and understand the financial disclosure and late cancel/no-show policy. Signature: Date: