Lifestyle and Metabolic Medicine

Transcription

1 Lifestyle and Metabolic Medicine New Patient Intake Form - fax completed form to or bring to your first appointment. Demographics First Name Date of Birth Mailing Address City, State, Zip code Preferred phone Secondary phone address Referred by Primary Care Physician / / Middle Initial Age Last Name Gender Male Female ( ) - Home Work Mobile ( ) - Home Work Mobile Medications Please list all current medications & supplements (including dosages) Medical History 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 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 Have you ever had an eating disorder? Yes No 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 Poroblems: Date last menstruated: Period every days No. of pregnancies Heavy Periods YES NO Irregular Periods YES NO Infrequent Periods YES NO Painful Periods YES NO No. of miscarriages Infertility issues? YES NO Nutrition History Do you have any adverse food reactions (intolerances and/or allergies)? Yes No Do you avoid certain foods? Yes No Have you ever changed your eating habits for a health reason? Yes No Have you ever changed your eating habits for any non-health related reason? Yes No

4 Current Nutrition Habits Are you currently following a particular diet or nutrition plan? Yes No How many meals do you eat per day? How many snacks 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/soft drinks, sweetened teas, juice, flavored coffees (vanilla, caramel, mocha, etc ), energy drinks, etc do you drink per week? What is your favorite meal? What is your least favorite meal? Are there any particular foods you crave regularly? Yes No Are there any foods that once you start eating them, you find it difficult to stop even when full? Yes No Check all factors 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 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 Do not plan meals or menus 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 better nutritional choices? Please explain. How many glasses of water do you drink per day? Please describe what you eat and drink on a typical day: Breakfast Lunch Dinner Snack(s) Time of day: Time of day: Time of day: Time of day: Time of day: Time of day: Food Frequency Questionnaire - How often do you eat the following? Food Daily 3x/wk 1-2x/wk Cheese & Yogurt (full fat) Cheese & Yogurt (low/no fat) Milk (whole) Milk (2% or nonfat) Milk Alternatives (soy, rice, etc) Red Meat Pork Chicken/Turkey Eggs Cold-water Fish (salmon, cod, etc) Other Fish/Seafood Beans/Legumes Soy Products (tofu, edamame) Meat Alternatives (eg. Tempeh) Monthly Rarely/Never

6 Food Daily 3x/wk 1-2x/wk Monthly Rarely/Never Cruciferous Vegetables Green Leafy Vegetables Summer Squashes Corn White Potatoes Winter Squashes Yams/Sweet Potatoes Root Vegetables (carrots, beets, turnips, ) Tomatoes Berries Apples/Pears Citrus Fruits Pit Fruits (plums, apricots,..) Tropical Fruits (eg. Mango) Nuts & Seeds Avocado Olives White Bread White Pasta White rice Pastries (cookies, muffins, cakes) Bagels/English Muffins Pancakes/Waffles Whole-Wheat Bread Brown/Wild Rice Other whole grains (quinoa, cornmeal, barley, etc.) Cold Breakfast Cereals Hot Breakfast Cereals (eg. Oatmeal, cream of wheat, ) Granola Bars/Energy Bars Chips/Pretzels/Crackers Frozen Meals/Entrees Ice Cream/Frozen Desserts Candy/Sweets Juice/Lemonade Soda (non-diet) Diet Soda Beer Wine Cocktails Flavored Coffees (eg. Mocha,...) Coffee Creamer (flavored) Half & Half

7 Food Daily 3x/wk 1-2x/wk Monthly Rarely/Never Margarine/Butter Substitutes Vegetable Oils Nut Butters Mayonnaise Cream Cheese Jam/Jelly Honey/Maple Syrup Physical Activity Questionnaire Do you engage in regular physical activity? Yes No Activity Minutes per session If yes, please complete the table below. Number of Days/Week Are you interested in becoming more physically active? Yes No limitations you may have. If yes, please explain any physical 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?

8 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. #1: #2: #3: Social History Relationship Status: Single Married Divorced Other Children/Dependents: How many? Religion: Employment: FT PT Where: Ages Position: Besides children, do you care for anyone else in your home? (ie. Elderly parent/relative, individual suffering from a disability, etc )

9 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