Cayuga Center for Healthy Living Health and Lifestyle Questionnaire. Name: Date of Birth: Today s date: Clinic visit date:
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1 Cayuga Center fr Healthy Living Health and Lifestyle Questinnaire Name: Date f Birth: Tday s date: Clinic visit date: Histry f weight lss/gain: Desired r gal weight: Lwest adult weight: Highest adult weight (nn-pregnant): When did yu begin gaining excess weight? Starting a new jb After High Schl After Cllege After getting married After having children After surgery/injury Other Please list weight lss prgrams/diets/meds tried with duratin: DIET START DATE END DATE Atkins LA Weight Lss Cambridge Jenny Craig Medifast Nutrasystems Optifast TOPS Suth Beach Weight Watchers Other: Other: Maximum weight lst n any prgram: Histry f fd patterns Where are mst meals eaten? At hme alne At hme with family At hme with a friend At restaurants alne 1
2 At restaurants with family At restaurants with a friend Where d yu purchase r btain fd? D yu receive SNAP Benefits? Yes N Husehld special dietary restrictins: Wh usually cks? Wh grcery shps? Fd allergies r intlerances: Favrite fds: Fd dislikes: Prblem fds : What percent f the time d yu spend thinking abut fd and yur weight? Are yu uncmfrtable with hw much yu eat? Yes N D yu eat differently when yu are alne? D yu have difficulty chewing? Yes N D yu wear dentures? Yes N D yu have truble swallwing? Yes N D yu have difficulty swallwing pills? Yes N Weight lss barriers: Lw level f physical activity Eating/snacking t many times daily Amunts f fd eaten Kinds f fds eaten Eating ut t ften Lack f knwledge Eating t fast Scial events Irregular meal and snack times Eating due t bredm r stress Lack f ther satisfactins Overeating when alne Using fd as reward r cmfrt Lve the taste f fd Histry f eating behavir: Histry f Disrdered Eating: Anrexia nervsa Binge eating Binge eating disrder Bulimia Induced vmiting Laxative abuse Waking at night t eat Other Nne 2
3 Emtins assciated with eating: Anger Anxiety Bredm Cntrl Depressin Enjy taste Hunger Guilt Stress Other D yu think yu are currently underging a stressful situatin? Yes N Histry f activity/exercise Previus activity/exercise: Current activity/exercise: Physical limitatins: Chest discmfrt Dizziness Jint swelling Back pain Ft pain Jint pain Knee pain Leg pain Muscle pain Shrtness f breath Trn ligaments Histry f Tbacc Use: Tbacc Use: Never Frmer Current Type: Amunt: Start Date: Stp Date: Are yu expsed t secnd hand smke? Yes N 3
4 Hw ften d yu have the fllwing fds and beverages? Milk, Ygurt Vegetables Fruit Red Meat Red Meat Pultry, Fish Sweets Regular sda Fast r fried fd Daily Weekly Seldm Never Hw wuld yu describe the size f yur servings? Small Average Large Hw much tea, cffee, r ther caffeinated beverages d yu cnsume? What ther beverages d yu drink? If yu have nt been keeping a fd recrd, please jt dwn what yu eat and drink n a typical day. If yu never have a typical day, please write dwn what yu ate yesterday: Breakfast: Mrning snacks: Lunch: Afternn snacks: Dinner: Evening snacks: The fllwing 3 questins are fr Bariatric Patients Only. Other patients please cntinue n page 5. What kind f surgery are yu interested in? What type f exercise d yu plan t d when recvered frm surgery? Please check hw yur partner, spuse, family, friends, r emplyer feel abut yur planned surgery: Partner Spuse Family Friends Emplyer Very critical Neutral Very supprtive Nt applicable Des nt knw 4
5 Past Medical Histry: Please indicate whether yur medical histry includes any f these cnditins: YES NO PROBLEM COMMENTS Anxiety Cancer Diabetes Depressin Difficulty breathing High bld pressure High chlesterl Heart disease Mental illness Obesity Ostearthritis Osteprsis Rheumatid arthritis Sleep apnea Stmach/digestive prblems Strke Thyrid disease Other WOMEN ONLY: D yu have menstrual perids? Yes N If yes: Hw frequent are yur perids? Hw lng d they last? Hw heavy are they? What d yu use fr cntraceptin? If n: please check reasn: Hysterectmy Menpause Other D yu have any leakage f urine when yu cuch, sneeze r exercise? Yes N Tell us abut yur surgical histry and medically related events (fr example, appendectmy, and heart attack) SURGERY OR MEDICAL EVENT DATE 5
6 Family health histry: Has anyne had any f these medical prblems and if s, indicate wh (family includes parents, grandparents, siblings and children) YES NO PROBLEM FAMILY MEMBER(S) Cancer type Diabetes High Bld Pressure High Chlesterl Heart Disease Mental illness Obesity Ostearthritis Osteprsis Rheumatid arthritis Strke Thyrid disease Other Medicatins and Supplements: Please list any prescriptin and nn-prescriptin medicatins yu are taking (if yu have a current list, please bring it with yu instead f filling this sectin ut) MEDICATION/SUPPLEMENT DOSE MEDICATION/SUPPLEMENT DOSE Allergies: Please list any drug r fd allergies/intlerances and the reactin D yu have latex allergies? Yes N Scial histry: What is yur ccupatin? Current emplyment status? Wh lives in yur husehld? Relatinship status? Alchl cnsumptin: Nne 1-2 drinks per day Mre than 2 drinks per day Recreatinal drugs: Yes N 6
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