Lipid Clinic Name DOB / / Primary Care MD Cardiologist Endocrinologist

Transcription

1 Lipid Clinic Name DOB / / Date Primary Care MD Cardiologist Endocrinologist Allergies to medications (please include reaction) Marital Status (Please circle) Educational Level (Please circle highest level) Single Married Widowed Partner Divorced Grade High Vocational College Occupation Do you enjoy using the internet? YES NO Do you have any physical limitations? YES NO Typical Day Activity at work Check most appropriate- deferred if retired Minimal Desk most of the day Moderate - Walking most of the day List Top 4 Commonly Eaten Foods: Intense Jogging/ cycling most of the day Typical Week Physical Activity Habits Please include length of time & how often Typical Day Dietary Intake Walking/running Please list the types of foods Gardening Breakfast Cycling Lunch Swimming Dinner Other Snacks Smoking History Never Smoked Occasional /year Smoked x yrs, Quit years ago Quit x, Restarted currently smoking /day Currently smoke day for years If smoked (please circle): cigarettes pipe cigar Family History Please obtain as much information as possible focusing on High Cholesterol, Diabetes, and Heart Problems with their ages of occurrence Mother Father Sibling Sibling Sibling Current Medications & Dosages Alcohol Intake Please quantify drinks per: Never Occasional / year Weekly / week Monthly /month What are you most concerned about? Having a Heart Attack Having a Stroke Liver Problems Other Have you had problems with cholesterol lowering medications in the past? No If so please list medication and reaction Do you take supplements? No If so please list

2 Please list any areas you would like to focus on or any concerns that you have pertaining to your cardiovascular risk. When was your last dental exam/ cleaning? Do you use an electric rechargeable toothbrush? (Please circle for next 4 questions) YES NO How often do you brush your teeth? <1x day 1/ day 2/ day 3/ day How often do you floss your teeth? Never Monthly or as needed (food stuck) Couple times a week Daily Do your gums bleed with either of the above? YES NO Past Medical History Please check all that apply & your age when diagnosed/ occurred: Pancreatitis Polycystic Ovarian Syndrome High Cholesterol Schizophrenia High Blood Pressure Gout Heart Attack Osteoporosis Heart Problems Obstructive Sleep Apnea Stroke Snoring, headache and daytime tiredness Diabetes Numbness, Tingling, Burning in Hand and/or Aortic Aneurysm Feet Kidney Problems Fatty Liver Liver Problems Gestational Diabetes Poor blood flow to extremities Pre-eclampsia Thyroid Problems H. Pylori Infection Rheumatoid Arthritis Erectile dysfunction Lupus Periodontal Disease/ Psoriasis Breast Cancer survivor Migraines with Aura How would you rate your current health? How many hours a night do you sleep? Excellent Fair Good Poor Do you feel well rested? YES NO Depends How would rate your current diet? How many hours of TV do you watch daily? Excellent Fair Good Poor < >6 Are you satisfied with your weight? Do you have/own: Yes No gym membership pedometer How would you describe your stress level: treadmill At work: minimal moderate high stationary bike At home: minimal moderate high outside bike Does it feel manageable? Yes No How do you like to relax?

3 NWLRC Fat Intake Scale Pick the answer which best describes the way you have been eating over the past month. 1. How many ounces of meat, fish or poultry do you usually eat?** 1. I do not eat meat, fish or poultry. **3 ounces or meat, fish or chicken is 2. I eat 3 ounces or less per day. any ONE of the following: 1 reg. 3. I eat 4-6 ounces per day. hamburger, 1 chicken breast, 1 chicken 4. I eat 7 or more ounces per day. leg (thigh and drumstick), 1 pork chop or 3 slices of pre-sliced lunch meat. 2. How much cheese do you eat per week? 1. I do not eat cheese. 2. I eat whole mild cheese less than once a week and/or use only low fat cheese such as diet cheese, low fat cottage cheese, or ricotta. 3. I eat whole milk cheese once or twice per week (Cheddar, Swiss, Monterey Jack) 4. I eat whole milk cheese three or more times per week. 3. What type of milk do you use? 1. I use only skim or 1% milk, or don t use milk. 2. I usually use skim milk or 1% milk, but use others occasionally. 3. I usually use 2% or whole milk. 4. How many visible egg yolks do you use per week? 1. I avoid all egg yolks or use less than one per week and/or use only egg substitute. 2. I eat 1-2 egg yolks per week. 3. I eat 3 or more egg yolks per week. 5. How often do you eat these meats: regular hamburger, bologna, salami, hot dogs, corned beef, spareribs, sausage, bacon, braunsweiger, or liver? Do not count others. 1. I do not eat any of these meats. 2. I eat them about once per week or less. 3. I eat them about 2 to 4 times per week. 4. I eat more than 4 servings per week. 6. How many commercial baked goods and how much regular ice cream do you usually eat? (Examples: cake, cookies, coffee cake, sweet rolls, donuts, etc. Do not count low fat versions.) 1. I do not eat commercial baked goods and ice cream. 2. I eat commercial baked goods or ice cream once per week or less. 3. I eat commercial baked goods or ice cream 2 to 4 times per week. 4. I eat commercial baked goods or ice cream more than 4 times per week.

4 7. What is the main type of fat you cook with? 1. I use nonstick spray or I do not use fat in cooking. 2. I use a liquid oil (Examples: safflower, sunflower, corn, soybean, and olive oil.) 3. I use margarine 4. I use butter, shortening, bacon drippings, or lard. 8. How often do you eat snack foods such as chips, fries or party crackers? 1. I do not eat these snack foods. 2. I eat one serving of these snacks per week. 3. I eat these snacks 2 to 4 times per week. 4. I eat these snack foods more than 4 times per week. 9. What spread do you usually use on bread, vegetables, etc? 1. I do not use any spread. 2. I use diet or light margarine. 3. I use margarine. 4. I use butter. 10. How often do you eat as a snack candy bars, chocolate, or nuts? 1. Less than once per week. 2. One to 3 times per week. 3. more than 3 times per week. 11. When you use recipes or convenience foods, how often are they low fat? 1. Almost always. 2. Usually. 3. Sometimes. 4. Seldom or never. 12. When you eat away from home, how often do you choose low fat foods? 1. Almost always. 2. Usually. 3. Sometimes. 4. Seldom or never. To Score: Add the points for each answer. If you have 24 or less, your diet is moderate to low in fat and cholesterol. If your score is greater than 24, look for high fat choices you could change. You have permission to copy, use, and modify this questionnaire. Please credit the Northwest Lipid Research Clinic, University of Washington, Seattle. For information about validity and scoring see Retzlaff, et al, American Journal of Public Health, February Northwest Lipid Research Clinic University of Washington 325 Ninth Avenue, Box Seattle, WA Tele 206/ ; retz@u.washington.edu

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6 Fatigue scale The Fatigue scale is a method of evaluating the impact of fatigue on you. This is a short questionnaire that requests you to grade your level of fatigue over the past week. During the past week, I have found that: Disagree Agree 1) My motivation is lower when I am fatigued ) Exercise brings on my fatigue ) I am easily fatigued ) Fatigue interferes with my physical functioning ) Fatigue causes frequent problems for me ) My fatigue prevents sustained physical functioning ) Fatigue interferes with carrying out certain duties and responsibilities ) Fatigue is among my 3 most disabling symptom ) Fatigue interferes with my work, family, or social life Scoring your results: Total Score : Now that you have completed the questionnaire, it is time to score your results and evaluate your level of fatigue. It s simple: Add the numbers you circled to get your total score Key: Score of >36, you may need further evaluation Score of <36 suggests that you may not be suffering from fatigue