Lifestyle Questionnaire Nutrition Consultation

Transcription

1 Diana Cullum-Dugan RDN LDN RYT 23 Main Street, Watertown, MA (617) (c) (617) (f) Lifestyle Questionnaire Nutrition Consultation Name Date of Visit: How did you hear about Namaste Nutrition? Online search Friend referral Medical provider referral Social Media (specify) MEDA Other WEIGHT HISTORY HEIGHT WEIGHT HIGHEST ADULT WEIGHT WEIGHT AT YEARS GOAL WEIGHT Dietitian will make the following calculations: BMI IDEAL BODY WEIGHT ADJUSTED BODY WEIGHT DAILY CALORIES (Lose) DAILY CALORIES (Maintain) Which of these methods have you tried to manage your weight (gain or lose)? Check all that apply Did it work? Y/N a. Dietitian / nutritionist b. Exercise c. Low calorie diet d. Very-low-calorie-diet (i.e., liquid, HMR, protein-sparing, Medifast) e. Formal group diet program (i.e., Weight Watchers, OA) f. Prescription diet drugs Please list medications g. Over-the-counter diet drugs (e.g. Alli, Hoodia) h. Psychological counseling / behavior modification i. Hypnosis J. Have you ever induced vomiting or used laxatives for weight loss? k. Have you engaged in excessive exercise to help you lose weight? If you did not maintain your weight change for at least 1 year, why do you think you were not successful? _ Do family members struggle with being overweight? (Circle those that apply) Father Mother Brother(s) Sister (s) Do they have a history of eating disorders (anorexia, bulimia, binge eating, compulsive overeating? Y N Do you Eat differently when you are alone? Eat when you are upset or nervous? Eat sweets or salty snacks? Tend to binge eat? Eat in front of the TV or computer? Eat meals or snacks in the car? Are you comfortable with the way you eat? Do you ever feel shame or guilt after eating? What percentage of time do you think about food, eating, and exercise? % How do you feel when you see your body? Extreme dislike Neutral Extreme Like 1

2 MEDICAL HISTORY: Circle all medical conditions that apply to you. a. Diabetes mellitus 1 or 2 b. High blood pressure c. High cholesterol d. Low back pain e. Arthritis/joint pain f. Sleep apnea (breathing or severe snoring problems at night) g. Asthma h. Heartburn (GERD) i. Gallbladder dz/gallstones j. Liver disease k. Kidney disease l. History of cancer If yes, specify m. Thyroid n. Menopause o. Surgery: p. Pregnancy q. Digestive health issues (circle) (IBS, stomach ulcers, ulcerative colitis, Crohn s disease Please list all vitamin and herbal products: Please list all present prescription medications/doses: Please list all allergies or intolerances (i.e., lactose): To any foods To any medications Do you smoke? Quantity? If you quit, for how long? How many hours of sleep do you get each night? EATING PATTERNS: Please pick the number that best describes how much these behaviors may influence your weight. 1 = Does not contribute 2 = Contributes a small amount 3 = Contributes a moderate amount 4 = Contributes a large amount 5 = Contributes the greatest amount a. Eating too much food b. Not eating enough food c. Overeating during the day d. Overeating at night e. Snacking between meals f. Binge and purge g. Eat because I m hungry h. Eating because I have cravings i. I cannot stop once I ve begun j. Eating because I m not full k. Eating because it tastes good l. Eating because it smells or looks good m.eating while cooking / preparing meals n. Eating when anxious o. Eating when tired p. Eating when bored q. Eating when stressed r. Eating when angry s. Eating when depressed/upset t. Eating when socializing u. Eating when happy v. Eating when alone w. Restricting food Please write any other factors that you feel may have contributed to your weight change. How many days a week do you eat the following meals? Meal Days per week Time Breakfast Morning snack Lunch Afternoon snack Dinner Nighttime snack Who prepares meals at home? Who meal plans? Who grocery shops? Describe your appetite: Strong, must eat when hungry. Variable, sometimes hungry or not; forget to eat if busy. Not hungry a lot; OK if I eat just a couple times a day. 2 Revised:

3 Please list the amount of the following you typically drink in a day. Fat-free or low-fat (2%) milk Whole milk Seltzer water Tonic water (diet or regular) Fruit juice Water Coffee Cream? Sugar? Coffee, specialty (specify type: ) Tea (black, green or herbal) Sugar-sweetened beverages (soda, Snapple) Diet soda, Vitamin Water, flavored water Alcohol (5 oz wine, 12 oz beer, 1.5 oz liquor) Vitamin water, Red Bull, specialty drinks During a typical week, how many meals do you eat at a fast-food or quick serve restaurant or coffee shop? Breakfast: Lunch: Dinner: During a typical week, how many meals do you eat at a traditional restaurant or cafeteria? Breakfast: Lunch: Dinner: How willing are you to record (online or paper) what you eat and drink? Very Neutral Not Very 24-HOUR FOOD RECALL: Please write down all the foods and drinks you consumed yesterday. Meal Time Food/drink (include how prepared) Amount Where did you eat this? Morning Meal Snack Midday Meal Snack Evening Meal Snack/Dessert 3 Revised:

4 Please check the frequency of these foods that you eat regularly. Meal How often do you eat these foods? Examples: Morning Meal daily most mornings 2-3 times a week Snacks 3 or more a day 1-2 a day few times a week Fatty foods 4 or more a week 2-3 times a week 2-4 times a month Grains/Starches nearly always eat refined grain product eat mostly refined grain product eat mostly whole-grain product Protein/Meats Vegetables and Fruits eat only whole-grain product nearly always eat animal proteins eat mostly animal proteins eat mostly vegetable proteins eat only vegetable proteins 5 or more a day 2-4 a day 1-2 a month roll, pastry, donut cold or hot cereal (oatmeal) eggs, sausage, home fries fruit and yogurt chips, pretzels or nuts energy bar or candy bar pastries, cookies or other baked sweets candy, ice cream hamburgers, hot dogs, lunch meat, steaks, fast food cheese, whole milk, yogurt, cottage cheese butter, ice cream, chocolate cake, pastries, cookies, donut white bread, rolls, bagels, typical cereals regular pancakes and waffles, typical baked goods brown rice, quinoa, farro, old-fashioned oats whole wheat bread, rolls and bagels meats, poultry, fish, cheese, eggs legumes (beans and peas), hummus, nut foods soy (tofu, tempeh, edamame, veggie burgers/dogs) seitan (wheat gluten) green (spinach, kale, broccoli, turnip/collards, Swiss chard) red (bell pepper, beets, strawberry, apple, tomato, watermelon) orange (squash, melon, bell pepper, carrots, orange, grapefruit) blue (blueberries, eggplant, blackberry, plum, grapes/raisins) PHYSICAL ACTIVITY: What physical problems, if any, limit physical activity? How much do you enjoy physical activity? a. Not at all b. Moderately c. Greatly Please circle the types of physical activity you enjoy and have participated in during the last year. a. Walking (outside or treadmill indoors) b. Yoga (hatha, power, vinyasa, heated) c. Jogging / running d. Group exercise classes at gym (Barre, step) e. Biking (outside or indoor spin class) f. DVD exercises at home (P90X) g. Tennis / golf h. Swimming i. Personal training j. CrossFit, Pilates, Indo-Row, Curves k. Dancing l. Strength training / weight lifting m. Elliptical / arc trainer Please circle the best response below (relative to the past 2 months): FREQUENCY times per week times per week times per week 1 A few times per month INTENSITY 4 Aerobic activities that result in heavy breathing and sweating (e.g., high impact aerobics, running, speed swimming, distance cycling). 3 Moderate aerobic activity (e.g., normal bike riding, jogging, low impact aerobics). 2 Moderate aerobic activity (e.g., volleyball, moderate speed walking 1 Light aerobic activity (e.g., normal walking, golf). TIME 3 Over 30 minutes 2 30 minutes 1 Under 30 minutes 4 Revised:

5 READINESS CHECKLIST: Who, if anyone, is supportive of your decision to begin weight change efforts now? How important is it that you manage your weight at this time? Pick a number between 1 and 10 in which 1 = not important and 10 = greatest importance. My number = What are the benefits to you of weight change? What will you have to sacrifice, i.e., what are the down sides of changing your weight right now? How confident are you that you will be able to significantly change your eating and exercising habits. Pick a number from 1 to 10 in which 1 = not at all confident and 10 = extremely confident. My number = How much time daily can you devote to this effort? If you decide to make the choice to live healthier, which of the following, if any, would work best for you? Increase physical activity Watch less TV Eat more colorful fruits & vegetables Spend less time on the computer Limit eating out / fast food Eat less fat / fewer fatty foods Eat more whole grains / high fiber foods Drink fewer sugar-sweetened drinks Reduce calories / reduce portion size Learn more about meal preparation Eat fewer desserts and sweet foods Get more involved in menu planning Circle the top 5 values that are most important to you as you live your life. Appreciation Energy Humility Professionalism Authenticity Excellence Humor Prosperity Balance Faith Independence Purposefulness Beauty Family Innovation Quality Career Financial security Integrity Respect Clarity Fitness Joyfulness Responsibility Commitment Freedom Leadership Self-esteem Compassion Friendship/Social Life Loyalty Spirituality/Religion Connection Generosity Parenting Steadiness Courage Gratitude Patience Teamwork Creativity Growth Perseverance Tolerance Devotion Health Playfulness Unconditional Love Education Honesty Pleasure Wisdom 5 Revised:

6 6 Revised: