Patient Behavioral & Lifestyle Assessment

Transcription

1 Patient Behavioral & Lifestyle Assessment Child s Name: D.O.B.: Parent Name: Relationship: Date: Vegetables (Do not include French fries in your count) Evaluate the average number of fist-size servings of vegetables that you & your child eat each day (Your child s serving should be the size of their fist = 1 serving). Asparagus, broccoli, carrots, green beans, mushrooms, peas, squash, sweet potatoes, tomatoes, turnip greens. 5 servings per day of veggies 4 servings per day of veggies 3 servings per day of veggies 2 servings per day of veggies 1 servings per day of veggies 0 servings per day of veggies Whole Grains/Carbohydrates/Cereals This section asks you to evaluate the average number of palm-size servings of grains, starches, and carbohydrates that are consumed each day. Examples: bread (1 slice), corn muffins, rice, pasta, oatmeal, crackers, cereal, potatoes, etc. 6 servings per day 5 servings per day 4 servings per day 3 servings per day 1-2 servings per day 0 servings per day High-Fat ats Evaluate the average number of palm size servings of high-fat meats you & your child eats each day. Examples are poultry with the skin, bacon, sausage, luncheon meats, fish packed in oil, etc). 4 or more servings daily 3 servings daily 2 servings daily 1 serving daily 0 servings daily Lean ats Evaluate the number of palm size servings of lean meats you & your child have daily. (poultry without the skin, lean cuts of beet/pork, fish packed in water,). 4 or more servings daily 3 servings daily 2 servings daily 1 serving daily 0 servings daily Fried Foods Evaluate the average number of palm size servings of fried. Examples are: fried fish, chicken, cheese sticks, onion rings, French-fries. 4 or more servings daily 2-3 servings daily 1-2 servings daily No servings daily Fast Food For this section, consider the number of times you & your child ate at a fast food restaurant, on average, over the last three months (this includes individual visits to restaurants with family, friends, alone, etc). McDonald s, Burger King, Buffets. 5+ servings per week 3-4 times per week 1-2 times per week Not at all

2 Oils and Fats This section allows you to evaluate the average number meals eaten with these additives whether added in cooking or at the table (butter, oil, shortening, lard (hydrogenated oils), sour cream, etc). 4+ meals with these additives daily 3 meals daily 2 meals daily 1 meal daily 0 meals cooked or eaten with additives Fruits This section allows you to evaluate the average number of fist-size or whole piece servings of fruits you & your child eats each day. Examples of fruits include, but are not limited to, apples, berries, cantaloupe, grapefruit, grapes, honeydew, kiwi, kumquats, mangoes, nectarines, oranges, papayas, peaches, pineapple, plums, prunes, rhubarb, tangerines, strawberries, and watermelon. Do not count fruit juice on this question. 4 or more servings of fruit 3 servings of fruit 2 servings of fruit 1 serving of fruit 0 servings of fruit Dairy and Calcium This section asks you to evaluate the number of servings of calcium-containing you & your child consumes each day. This includes yogurt, milk (8 ounces), cheese (1 ounce), calcium-fortified orange juice, broccoli, collard greens, turnip greens. Type of milk (whole, 2%, 1%, or fat-free) 3 servings of milk or calciumcontaining 2 servings of milk or calciumcontaining 1 serving of milk or calciumcontaining 0 servings of milk or calciumcontaining On average how many meals do you typically eat in a day? 1-2 meals 3-4 meals 5-6 meals More snacking than regular meal servings Sugared Drinks For this question, estimate you & your child's intake of soft drinks, sodas (regular), fruit drinks, fruit juice, and sports drinks. Do not include diet drinks. A serving size is 12 ounces for soft drinks (1 regular can size soda), but 8 ounces for fruit drinks and fruit juice. SERVINGS PER DAY 4 or more servings 1 serving 3 servings 0 servings (if you drink any at all, please describe ) Water For this section, estimate how many 8 ounce servings of water you & your child drinks on an average or typical day 8+ servings of water per day 7 servings of water per day 6 servings of water per day 5 servings of water per day 4 servings of water per day 3 servings of water per day 2 servings of water per day 1 serving of water per day 0 servings of water per day Sweets & Snacks Highly processed with high concentrations of simple sugars are included in this category. Items in this category include cakes, pies, ice cream, candy bars, chips, pretzels, cookies, etc. Once again, think of you & your child's average intake over the last three to four months. Please rate how many servings are consumed. 6 or more servings per day 3 servings per day 5 servings per day 1 serving per day 4 servings per day 0 servings per day (if you don t eat these every day, please describe per week or month ) Page 2 of 6 Rev: 1/2013

3 Do you have any special dietary needs (e.g., diabetes, high blood pressure, etc)? Diabetes Liver diet High blood pressure Gluten free High Cholesterol Dairy free Kidney diet Low sodium Do you take any nutritional supplements? Herbal Protein Vitamins Minerals Daily Sometimes Do you consume any energy drinks? (Red Bull, Monster, 5 Hour Energy, Amp) Daily Never Sometimes Family als at Home For this section, we'll look at the number of meals per week, on average, over the last three to four months, in which your family (parents and the child you are rating) sat down to share a meal together at home: More than 5 meals per week 3-4 meals per week 1-2 meals per week No meals as a family in the average week Problem Eating Areas (Please check all that apply) Sometimes I hide when I am eating Use food as a reward system at home Eating when angry/stressed/bored Love sweets and can t stay away from them Eating too large of portions or more than 2 servings Eating the wrong kinds of (fried food, fast, candy, sweets) Usually skip meals Never sure when feeling full Eating when sad/depressed Eating when happy Eating meals at the wrong time of day (and after 10pm) Emotional/Behavioral Does the child ever eat large amounts of food, in a discrete period of time, where he/she does not seem to be able to stop eating despite feeling uncomfortably full? Yes No How many times a week does it occur? 5+ more times weekly How many times a month? Does the child experience a loss of control? Yes No How long does the eating episode usually last for? 15 minutes 30 minutes 45 minutes 1 hour 2+ hours 3-4 times weekly 1-2 times weekly Does the child express feelings of guilt and shame after engaging in such eating patterns? Yes No If yes, please indicate what the child may have said to you in response to such feelings of shame and guilt: Did the child ever engage in compensatory behaviors (fasting, excessive exercising, use of laxatives, vomiting) right after engaging in a food binge? Yes No How often does this happen? With every binge Sometimes with the binge Rarely with the binge Page 3 of 6 Rev: 1/2013

4 What type of compensatory behavior(s) would the child typically engage in? Fasting Excessive exercising Use of laxatives vomiting Does the child feel ashamed about his/her body? Yes No Somewhat Activity /Exercise For children of elementary school age, activities with moderate exertion might include running, playing on playground equipment, hide-and-seek, etc. For middle school and high school children, moderate exercise would include activities such as swimming, biking, or brisk walking, basketball. Please rate how many days per week that you & your child engages in activities with moderate exertion (where the heart beats fast and you breathe hard) and the average amount of time minutes per day minutes per day minutes per day minutes per day minutes per day minutes per day 60+ minutes per day 7 days per week 5-6 days per week 3-4 days per week 1-2 days per week None What types of exercise do you engage in? Walking slowly Walking briskly (heart beat is faster) Biking (spinning class or bike ride) Group exercise (aerobics, dance) Swimming Soccer Baseball Basketball Football Volleyball On average how many days per week, do you exercise as a family? None 1-2 days 3-4 days 5-6 days Daily Do you have home exercise equipment or access to a gym available to you? Have a gym available (Have/Do Not Have a membership) I have home equipment (Treadmill/Elliptical/stationary bicycle) I have free weights (bar bells): What weight: Own Bicycle, rollerblades/skates, I have an exercise ball/bouncing ball List your favorite things to do in your free time (Indoor & Outdoor) Reading Drawing/Coloring Video Games Television Playing on computer Craft/Hobby Skateboarding Riding Bike Swimming Playing a sport Playing with friends outside Going to the park Walking dog Other On average, what time does your child fall asleep during the weeknights? 11 pm or later 8 pm 10 pm 7 pm 9 pm On average, what time does your child fall asleep during the weekends? 11 pm or later 8 pm 10 pm 7 pm 9 pm Page 4 of 6 Rev: 1/2013

5 On average, what time does your child usually wake up on weekday mornings? 9 am or later 6 am 8 am 5 am 7 am On average, what time does your child usually wake up on weekend mornings? 10 am or later 7 am 9 am 6 am or earlier 8 am Do you wake up in the middle of the night, if so, how many times? 5 times or more per night 2 times per night 4 times per night 1 time per night 3 times per night None How long does each sleep session (between awakenings) last? 5 + more hours 4 hours 3 hours Reasons for waking up during sleeping periods? Shortness of breath Snoring Nightmares Bedwetting Do you feel rested when waking up in the morning? Yes Somewhat Do you or your child take a nap during the day? Yes No Daily How long is the nap during the day? 4+ hours 3 hours 2 hours Is there a television in your bedroom? Yes Do you fall asleep using electronic devices (TV, computer)? Yes 2 hours 1 hour None Frequent urination Thirsty Night sweats Leg cramps No 1-2 times weekly 3-4 times weekly Only on weekends 1 hour 30 minutes 15 minutes No No Page 5 of 6 Rev: 1/2013

6 TV/Internet/Video Games Think of you & your child s average media activity over the past 3 to 4 months and check all boxes that apply: AMOUNT OF MEDIA EXPOSURE (television, videos, cell phone/music, video games, wii, and computer activities) Less than 1 hour per day 1-2 hours per day PARENTAL MONITORING OF MEDIA EXPOSURE I always monitor what my child watches on TV and does on the Internet. I routinely monitor what my child watches on TV and does on the Internet. I rarely monitor what my child watches on TV and does on the Internet. I never monitor what my child watches on TV and does on the Internet. 3-4 hours per day 5 + hours per day Eating with the TV on Use this section to indicate the average number of meals and snacks eaten in front of the TV or with the TV on in the house. This would include the number of meals or snacks eaten at a kitchen or dining room table in which the TV was on. 3-5 meals per day 1-2 per day 5+ meals per week 3-4 per week None Please list the barriers/challenges to maintaining a healthier lifestyle: Demanding work/school hours Lack of planning Not knowing where to start making changes Financial Restraints History of yo-yo dieting or trying fad diets Extracurricular activities Unsafe neighborhood for walking/outside play Please base your responses to the following questions on the last two weeks: Always Often Sometimes Never Preoccupied with hiding and disguising body Concerned about social interactions because of weight Strong dissatisfaction with body Believes he/she will be happy if he/she was thin Avoids social situations because of physical appearance Makes negative statements about his/her body ****For Office Use Only: To be completed by Healthy 100 Kids Staff**** General Health Goals Increase Fruits/Vegetables Increase Grains Increase Dairy/Calcium Increase Lean ats Increase Water Decrease Sugared Drinks Decreased Sweets/Snacks Decrease Screen Time Increase Activity/Exercise Improved Fitness Abilities Improved Attitude Improved Self-esteem Improved Body Image Improved Slower, Mindfulness Improved Rest/Sleep Improved Blood Lipids Improved IR/ Prediab/ Diab Improved Cardiac Risk Improved Liver Disease Weight Loss Maintenance Page 6 of 6 Rev: 1/2013