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Health and Lifestyle Questionnaire

Download a printable version of the form here

Name:
Date of Birth:
Visit Date:
Please tell us the reason for your visit:

PERSONAL AND FAMILY MEDICAL & SURGICAL HISTORY
Please put a check in any applicable columns, and indicate which family member where necessary:

ConditionSelfFamily MemberComments
High blood pressure
High cholesterol
Diabetes
Prediabetes
Obesity
Sleep apnea
Arthritis
Hypothyroidism
GERD (reflux disease)
Asthma
COPD
Depression
Anxiety
Other mental illness
PCOS
Heart disease
Blood clots
Cancer
Kidney disease
Infertility
Gestational diabetes
Liver disease
Stroke
VeXus stasis
Urinary incontinence
Other

SURGICAL HISTORY
Please list any surgeries you have had, along with the date and surgeon:


HEALTH MAINTENANCE
Please tell us the approximate date of your most recent health screenings:

Pap Smear:
Mammogram:
Colon cancer screening:
Routine lab work:
Annual Physical:


Do you have menstrual periods? yes no
If yes: How frequent are your periods?
How long do they last?
How heavy are they?
What do you use for contraception?


a. Please select your current overall LEVEL OF HEALTH
Very poor health Excellent health
0 1 2 3 4 5 6 7 8 9 10


b. Within the past 12 months, you worried that your food would run out before you got money to buy more:
Often true   Sometimes true   Never true


c. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more:
Often true   Sometimes true   Never true


d. Rank the top 3 areas you would like to improve, with 1 being the most important and 3 the least important
Sleep   Weight Management
Nutrition   Exercise
Smoking Cessation   Diabetes
Stress Management      


e. How IMPORTANT is it for you to make changes in the area you ranked as #1?
Not at all Very
0 1 2 3 4 5 6 7 8 9 10


f. How CONFIDENT are you in your ability to make changes in the area you ranked as #1?
Not at all Very
0 1 2 3 4 5 6 7 8 9 10


g. How IMPORTANT is it for you to make changes in the area you ranked as #2?
Not at all Very
0 1 2 3 4 5 6 7 8 9 10


h. How CONFIDENT are you in your ability to make changes in the area you ranked as #2?
Not at all Very
0 1 2 3 4 5 6 7 8 9 10


i. How IMPORTANT is it for you to make changes in the area you ranked as #3?
Not at all Very
0 1 2 3 4 5 6 7 8 9 10


j. How CONFIDENT are you in your ability to make changes in the area you ranked as #3?
Not at all Very
0 1 2 3 4 5 6 7 8 9 10


k. What would you like to gain from your CCHL visit? Select all that apply
More medical/Scientific knowledge
Practical Health Tips
Accountability
Personalized plan
Other



Eating pattern
Please answer based on your typical eating habits

a. On average, how many cups (8 oz.) of caffeinated beverages do you drink per day (tea, soda, coffee, or energy drinks)?

0
1
2
3
4+

b. On average, how many cups (8 oz.) of sweetened beverages (soda, sports drinks, sweet tea, juice, etc.) do you drink per day?

0
1
2
3
4+

c. On average, how often do you have convenience or "snack food" per day (i.e. chips, candy, granola/protein bars, crackers, cookies, etc.)?

0
1
2
3
4+

d. On average, how many meals do you buy from a restaurant or fast food per week?

0
1
2
3
4+

e. On average, do you drink at least 8 glasses of water (8oz.) per day?

yes      no

f. Do you have any food allergies or sensitivities? If yes, please list here:

g. Do you avoid any particular foods? If yes, please explain here:

h. Have you ever had an eating disorder? If yes, please list here:

i. Do you use any vitamins or supplements? If yes, please list here:




FOOD RECALL: Which meals do you eat nearly every day? Give times and typical contents of each meal.
Breakfast Time:
Snack Time:
Lunch Time:
Snack Time:
Dinner Time:
Snack Time:
Drinks/Beverages:



EATING ATTITUDES

Check a response for each of the following statements
  Always Usually Often Sometimes Rarely Never
1. Am terrified about being overweight.
2. Avoid eating when I am hungry.
3. Find myself preoccupied with food.
4. Have gone on eating binges where I feel that I may not be able to stop.
5. Cut my food into small pieces.
6. Aware of the calorie count of foods that I eat.
7. Particularly avoid food with a high carbohydrate content (i.e. bread, rice, potatoes, etc.)
8. Feel that others would prefer if I ate more.
9. Vomit after I have eaten.
10. Feel extremely guilty after eating.
11. Am preoccupied by the desire to be thinner.
12. Think about burning up calories when I exercise.
13. Other people think I am too thin.
14. Am preoccupied with the thought of having fat on my body.
15. Take longer than others to eat my meals.
16. Avoid foods with sugar in them.
17. Eat diet foods.
18. Feel that food controls my life.
19. Display self-control around food.
20. Feel that others pressure me to eat.
21. Give too much time and thought to food.
22. Feel uncomfortable after eating sweets.
23. Engage in dieting behavior.
24. Like my stomach to be empty.
25. Have the impulse to vomit after meals.
26. Enjoy trying new rich foods.
  never 1x month 2-3x month 1x week 2-6x week 1x day or more
In the past 6 months have you:
a. Gone on eating binges where you feel that you may not be able to stop?
(defined as eating much more than most people would under the same circumstances and feeling that eating is out of control)
b. Ever made yourself sick (vomited) to control your weight or shape?
c. Ever used laxatives, diet pills, diuretics to control your weight or shape?
d. Exercised more than 60 minutes a day to lose or to control your weight?
e. Lost 20 lbs. or more in the past 6 months


Which of the following factors apply to your eating habits and current lifestyle? Select all that apply

Like healthy food   Don't like healthy food   Know how to cook healthy food
Fast eater   Eat slowly   Read nutrition labels
Rely on packaged or fast foods   Dislike cooking   Prepare meals at home
Do not plan meals   Eat a variety of foods   Always hungry
Late night eater   Negative relationship to food   Irregular eating pattern
No time to prepare healthy food   Don't know how to cook/td>   Live alone or eat alone often


Do any of the following situations or emotions cause you to eat? Select all that apply

Sadness   Pain   Insomnia
Anxiety   Joy   Fatigue
Social/family situations   Boredom   Stress
Happy        



Weight History:
a. How do you feel about your weight?
I am comfortable at my current weight
I would like to lose a few pounds
I would like to lose a significant amount of weight (>10 lbs.)
I would like to gain weight

b. What weight loss strategies have you tried in the past, if any (include commercial diets, prescription medications, and over the counter supplements)?

c. Maximum weight lost on any program:

EXERCISE
EXERCISE HABITS: AEROBIC/CARDIO TRAINING

a. During the average week, how many days do you exercise at a moderate to strenuous intensity (i.e. brisk walking or enough to break a light sweat)?   days.

b. During an average session, how many minutes do you exercise at a moderate to strenuous intensity (i.e. brisk walking or enough to break a light sweat)?   min.

  Total min/week (days x min)

c. List types of aerobic activities you do (i.e. walking, jogging, swimming, bicycling, dancing, etc):


EXERCISE HABITS: STRENGTH/RESISTANCE TRAINING

a. During the average week, how many days do you do strength/resistance training?   days.

b. How many minutes do you exercise with strength/resistance training?   min.

  Total min/week (days x min)

c. List types of activities you do (i.e. weight lifting, kettle bell, weight machines, exercise bands)


What MOTIVATES you or would motivate you to exercise? Check top three

Nothing would motivate me   Family or partner   Improve mood
Weight reduction   Control blood glucose   Body image
Increase energy   Reduce blood pressure   Decrease stress
Prevent heart disease   Prevent bone loss   Improve sleep
Increase self-esteem   Increase strength   Other:
Are there any BARRIERS or PROBLEMS that limit exercise? Check all that apply
No barriers   Depression   Work responsibility
Cost   Life transition period   Time
Fear   Pain   Family responsibility
Apparel   Energy   Other:
MENTAL HEALTH
  never seldom sometimes often always
a. How often have you felt that you were able to control the important things in your life?
b. How often have you felt lack of confidence about your ability to handle your personal problems?
c. How often have you felt that things were not going your way?
d. How often have you found it hard to let go of things that upset you?
How do you COPE with stress? Check all that apply
Meditation   Food (too much, too little)   Gambling
Distraction   Exercise   Spirituality/faith
Journaling   Hurting yourself (i.e. cutting)   Sex
Socializing with friends/family   Art   Counseling/psychotherapy
Recreational drugs   Television/video games   Prayer
Substances (tobacco, alcohol)   Pet therapy   Massage/body work
Other:
Over the last 2 weeks, how often have you been bothered by the following?
  NOT AT ALL SEVERAL DAYS MOST DAYS DAILY
a. Little interest or pleasure in doing things 0 1 2 3
b. Feeling down, depressed, or hopeless 0 1 2 3
c. Trouble falling asleep, staying asleep, or sleeping too much 0 1 2 3
d. Feeling tired or having little energy 0 1 2 3
e. Poor appetite or overeating 0 1 2 3
f. Feeling bad about yourself, or that you're a failure or have let yourself or your family down 0 1 2 3
g. Trouble concentrating on things, such as Reading the newspaper or watching television 0 1 2 3
h. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3
i. Thoughts that you would be better off dead or hurting yourself 0 1 2 3


If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
  Not at all
  Somewhat difficult
  Very difficult
  Extremely difficult
SLEEP
a. How many hours of sleep do you typically get in a 24-hour period?

b. Usual bedtime      Usual wake up time

c. Do you have a problem with:     falling asleep     middle of night awakening     wake up too early

d. Are you worried about your sleep?     Yes     No

e. Do you have any other sleep concerns? If yes, please explain:


f. Have you ever had a sleep study done?     Yes     No          If yes, was it at home     or     in a sleep lab?
SMOKING AND SUBSTANCE HISTORY
NICOTINE/TOBACCOM (i.e. cigarette, e-cigarettes, e-cigarettes/vaping, cigars, chew, snuff)

a. Do you use any of the nicotine/tobacco products listed above?   Yes     No
    If yes, do you want to quit using the nicotine/tobacco products?   Yes     No


ALCOHOL

a. Do you drink alcohol?    Yes     No

If yes, please answer the questions below:
a. What type of alcohol do you prefer?
b. On average, how many servings do you drink per day/week/month/year?

Do you use any recreational drugs (marijuana, cocaine, meth, etc.)?    Yes     No


TREATMENT HISTORY

a. Have you ever received treatment for a mental health problem?    Yes     No

b. Have you ever received treatment for drug or alcohol use?    Yes     No
Please let us know if you have any additional comments and questions.


Thank you for taking the time to answer our questions. Your efforts allow us to be more prepared for your clinic visit. We ask you to please check the box below, indicating that this information is accurate to the best of your ability. We look forward to seeing you in clinic.

Sincerely,
The Cayuga Center for Healthy Living Team


The above information provided is accurate to the best of my ability.


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