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:



Weight History:
How tall are you>
Desired or goal weight:
Lowest adult weight: When:
Highest adult weight (non-pregnant): When:
If you are overweight, when did you begin gaining excess weight?
Starting a new job    After High School    After College    After getting married
After having children    After surgery/injury    Other

Please list weight loss programs, diets, or medications you have tried, with approximate dates:
DIET START DATE END DATE
Atkin's
LA Weight Loss
Cambridge
Jenny Craig
Medifast
Nutrasystems
Optifast
TOPS
South Beach
Weight Watchers

Maximum weight lost on any program:


Eating pattern

Where are most meals eaten?
At home alone
At home with family
At home with a friend
At restaurants alone
At restaurants with family
At restaurants with a friend

Where do you purchase or obtain food?

Do you receive SNAP Benefits? yes    no

Do you have food allergies or intolerances?


Any household special dietary restrictions?


Who usually cooks?

Who grocery shops?

Favorite foods:

Food dislikes:

"Problem foods":

What percent of the time do you spend thinking about food and your weight?

Are you uncomfortable with how much you eat? yes    no

Do you eat differently when you are alone?

Do you have difficulty chewing? yes    no

Do you have trouble swallowing? yes    no

Do you wear dentures? yes    no

Do you have difficulty swallowing pills? yes    no

If you are overweight, what are some reasons?
Low level of physical activity
Eating/snacking too many times daily
Amounts of food eaten
Kinds of foods eaten
Eating out too often
Lack of knowledge
Eating too fast
Social events
Irregular meal and snack times
Eating due to boredom or stress
Lack of other satisfactions
Overeating when alone
Using food as reward or comfort
Love the taste of food

Any eating problems?
Anorexia nervosa
Binge eating
Bulimia
Induced vomiting
Laxative abuse
Waking at night to eat
Other:
None

Emotions associated with eating:
Anger
Anxiety
Boredom
Control
Depression
Enjoyment
Hunger
Guilt
Stress
Other:

Do you think you are currently undergoing a stressful situation? Yes No
If 'yes' please explain:


Activity and exercise

Previous activity/exercise:


Current activity/exercise:


Do you have any of these physical limitations?
Chest discomfort
Dizziness
Joint swelling
Back pain
Foot pain
Joint pain
Knee pain
Leg pain
Muscle pain
Shortness of breath
Torn ligaments



Tobacco use

Tobacco Use:
Never   
Former    Type: Amount:
Current    Type: Amount:
Start Date: Stop Date:

Are you exposed to second hand smoke? yes    no


Food pattern

How often do you eat the following foods and beverages?
  Daily Weekly Seldom Never
Milk, yogurt
Vegetables
Fruit
Red meat
Poultry, fish
Sweets
Regular soda
Fast or fried food


How would you describe the size of your servings?
Small Average Large


How much tea, coffee, or other caffeinated beverages do you consume?



What other beverages do you drink?


If you have not been keeping a food record, please jot down what you eat and drink on a typical day. If you never have a "typical" day, please write down what you ate yesterday:

Breakfast:
Morning snacks:
Lunch:
Afternoon snacks:
Dinner:
Evening snacks:

The following three questions are for bariatric patients only
- others please continue below.


What kind of surgery are you interested in?

What type of exercise do you plan to do when recovered from surgery?


Please check how your partner, spouse, family, friends, or employer feel about your planned surgery:
  Very criticalNeutralVery supportive Not applicableDoes not know
Partner/Spouse
Family
Friends
Employer

ALL—continue here.
Please indicate whether your medical history includes any of these problems:


YesNoProblem HistoryComments
Anxiety
Cancer
Diabetes
Depression
Difficulty breathing
High blood pressure
High cholesterol
Heart disease
Mental illness
Obesity
Osteoarthritis
Osteoporosis
Rheumatoid arthritis
Sleep apnea
Stomach/digestive problems
Stroke
Thyroid disease
Other

Women Only:
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?
If no, please check reason:
Hysterectomy
Menopause
Other-please describe:

Do you have any leakage of urine when you cough, sneeze or exercise?
yes no

ALL—continue here:
Surgeries and medically related events (for example: appendectomy, heart attack):

Surgery or Medical Event Date
Additional Surgery or Medical Event Information:

Family history
Please indicate who in your family has had these problems (include parents, grandparents, siblings and children)
Yes No Problem History Family Member(s)
Cancer - type
Diabetes
High blood pressure
High cholesterol
Heart disease
Mental illness
Obesity
Osteoarthritis
Osteoporosis
Rheumatoid arthritis
Stroke
Thyroid disease
Other

Medications and Supplements:
Please list any prescription and non-prescription medications you are taking. If you have a current list, please bring it with you instead of filling this section out.

Medication/Supplement Dose Medication/Supplement Dose

Allergies: Please list any drug or food allergies or intolerances, and what symptoms you have


Do you have latex allergies? Yes No

Social History:
What is your occupation?
What is your current employment status?
Who lives in your household?
Relationship Status:
How much do you sleep each day, on average?
Usual bedtime:    Usual wake-up time:
Alcohol Intake:
None    Number of drinks on occassion    Number of days per week you drink

Recreational drugs: Yes    No

For all patients:
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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