ABOUT SSL CERTIFICATES 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/TOBACCO (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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